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City of Chicago

Office Of the City Clerk

02015-6394

Document Tracl<ing Sheet

Meeting Date:

9/24/2015

Sponsor(s):

Misc. Transmittal

Type:

Ordinance

Title:

Zoning Reclassification Map No. 4-E at 920-1006 S


Michigan Ave and 1011-1015 S Wabash Ave - App No.
18503
Committee on Zoning, Landmarks and Building Standards

Committee(s) Assignment:

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

SECTION 1: That Title 17 of the Municipal Code of Chicago, Chicago Zoning


Ordinance, be amended by changing all the DX-12 and DX-16 Downtown Mixed Use
District symbols and indications as shown on Map No. 4-E in the area bounded by:

a line 134.28 feet south of and parallel to East 9 Street; South Michigan
Avenue; a line 56.07 feet north of and parallel to East 11* Street; the alley
next west of and parallel to South Michigan Avenue, the alley next north of
and parallel to East 11* Street, the alley next east of and parallel to South
Wabash Avenue, a line 99.33 feet north of and parallel to East 11* Street;
South Wabash Avenue; a line 135.40 feet north of and parallel to East 11
Street; a line 240.94 feet west of and parallel to South Michigan Avenue,
to the designation of DX-16 Downtown Mixed Use District and a corresponding use
district is hereby established in the area above described.

SECTION 2:

That Title 17 of the Municipal Code of Chicago, Chicago Zoning

Ordinance, be amended by changing all the DX-16 Downtown Mixed Use District
symbols and indications as shown on Map No. 4-E in the area bounded by:
th

a line 134.28 feet south of and parallel to East 9 Street; South Michigan
Avenue; a line 56.07 feet north of and parallel to East 11* Street; the alley
next west of and parallel to South Michigan Avenue, the alley next north of
and parallel to East 11* Street, the alley next east of and parallel to South
Wabash Avenue, a line 99.33 feet north of and parallel to East 11* Street;
South Wabash Avenue; a line 135.40 feet north of and parallel to East 11*
Street; a line 240.94 feet west of and parallel to South Michigan Avenue,

to the designation of a Residential Business Planned Development which is hereby


established in the area above described, subject to such use and bulk regulations as are
set forth in the Plan of Development attached herewith and made a part thereof and to
no others.

SECTION 3:

This ordinance shall take effect upon its passage and due publication.

PLANNED DEVELOPMENT STATEMENTS


1. The area delineated herein as Residential Business Planned Development Number
,
("Planned Developmenf) consists of approximately 46,287 square feet of property which is
depicted on the attached Plarmed Development Boundary and Properly Line Map
("Property") and is owned, controlled or zoning consent has been received by the Applicant,
1000 South Michigan Equifies, LLC.
2. The requirements, obligations and conditions contained within this Planned Development
shall be binding upon the Applicant, its successors and assigns and, if different than the
Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the
Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different
than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to
the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the
time of application for amendments, modifications or changes (administrative, legislative or
otherwise) to this Planned Development are made, shall be under single ownership or
designated control. Single designated control is defined in Section 17-8-0400 of the Zoning
Ordinance.
3. All applicable official reviews, approvals or permits are required to be obtained by the
Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or
alleys or grants of easements or any adjustment of the right-of-way shall require a separate
submittal to the Department of Transportation on behalf of the Applicant or its successors,
assign or grantees. Any requests for grants of privilege, or any items encroaching on the
public way, shall be in compliance with the Plans.
Ingress or egress shall be pursuant to the Plans and may be subject to the review and
approval of the Departments of Planning and Development and Transportafion. Closure of
all or any public street or alley during demolition or construcfion shall be subject to the
review and approval of the Department of Transportafion.
All work proposed in the public way must be designed and constructed in accordance with
the Department of Transportation Construction Standards for Work in the Public Way and in
compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any
Part II approval, the submitted plans must be approved by the Department of Transportation.
4. This Plan of Development consists of 15 Statements: a Bulk Regulafions Table; an Existing
Zoning Map; an Existing Land-Use Map; a Plarmed Development Boundary and Property
Line and Sub-Area Map; Site Plan / Ground Floor Plan; Green Roof and Landscape Plan;
Building Secfion Plan; and Building Elevations (North, South, East and West) prepared by
Jahn Architecture and dated September 24, 2015, submitted herein. Full-sized copies of the
Site Plan, Landscape Plan and Building Elevations are on file with the Department of
Planning and Development. In any instance where a provision of this Planned Development
conflicts with the Chicago Building Code, the Building Code shall control. This Planned
Development conforms to the intent and purpose of the Zoning Ordinance, and all
AppliciUit.
Address.
introduced.
Plan Commission.

1000 SOUTH MICHIGAN EQUITIES, LLC


920-1006S MICHIGAN AVE.. 1011-I0I5 S. WABASH AVE.
September 24, 2015
TBD

requirements thereto, and satisfies the established criteria for approval as a Plarmed
Development. In case of a conflict between the terms of this Planned Development
Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control.
5. The following uses are permitted in the area delineated herein as a Residential Business
Planned Development. In each of the following Sub Areas, the following uses shall be
permitted in this Plarmed Development:
Sub-Area A: residential uses, including up to 506 dwelling units, commercial uses,
general retail sales, eating and drinking establishments, liquor sales as an incidental use,
accessory parking, of which 45% of the required residential parking (maximum 264
spaces) may be leased out on a daily, weekly or monthly basis to persons who are not
residents, tenants, patrons, employees or guests of the principal uses, co-location of
wireless telecommunication and satellite facilities, related facilities and accessory uses.
Sub-Area B: office, commercial uses, general retail sales, school, college, universities,
day care, eating and drinking establishments, liquor sales as an incidental use, accessory
parking, co-location of wireless telecommunication and satellite facilities, related
facilities and accessory uses.
6. On-Premise signs and temporary signs, such as construction and marketing signs, shall be
permitted within the Planned Development, subject to the review and approval of the
Department of Planning and Development. Off-Premise signs are prohibited within the
boundary of the Planned Development.
7. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply.
The height of any building shall also be subject to height limitations, i f any, established by
the Federal Aviation Administration.
8. The maximum permitted Floor Area Ratio ("FAR") for the site shall be in accordance with
the attached Bulk Regulations Table. For the purposes of FAR calculations and
measurements, the definitions in the Zoning Ordinance shall apply. The permitted Floor
Area Ratio identified in the Bulk Regulations Table has been determined using a Net Site
Area of 46,287 square feet and a base FAR of 16.00. The improvements to be constructed on
the Property will utilize the following series of FAR bonuses:
Description (list of all bonuses applied for and calculations)
Base FAR:
Concealed Parking Fafade
Setback Bonus
Green Roof Bonus
Affordable Housing Bonus
Total FAR:
Applicant
Address:
Introduced.
Plan Commission

1000 SOUTH MICHIGAN EQUITIES. LLC


920-1006 S. MICHIGAN AVE., 1011-1015 S. WABASH AVE.
September 24, 2015
TBD

FAR
16.00
2.02
2.45
1.03
1.37
22.87

9. Upon review and determination, "Part I I Review", pursuant to Section 17-13-0610 of the
Zoning Ordinance, a Part II Review Fee shall be assessed by the Department of Planning and
Development. The fee, as determined by staff at the time, is final and binding on the
Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II
approval.
10. The Site and Landscape Plans shall be in substantial conformance with the Landscape
Ordinance and any other corresponding regulations and guidelines. Final landscape plan
review and approval will be by the Department of Plaiming and Development. Any interim
reviews associated with site plan review or Part II reviews, are conditional until final Part II
approval.
11. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles
promulgated by the Commissioners of the Departments of Streets and Sanitation,
Envirormient and Buildings, under Section 13-32-125 of the Municipal Code, or any other
provision of that Code.
12. The terms and conditions of development under this Planned Development ordinance may be
modified administratively, pursuant to section 17-13-0611-A ofthe Zoning Ordinance by the
Zoning Administrator upon the application for such a modification by the Applicant, its
successors and assigns and, i f different than the Applicant, the legal title holders and any
ground lessors.
13. The Applicant acknowledges that it is in the public interest to design, construct and maintain
the project in a manner which promotes, enables and maximizes universal access throughout
the Property. Plans for all buildings and improvements on the Property shall be reviewed and
approved by the Mayor's Office for People with Disabilities to ensure compliance with all
applicable laws and regulations related to access for persons with disabilities and to promote
the highest standard of accessibility.
14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and
maintain all buildings in a manner that provides healthier indoor environments, reduces
operating costs and conserves energy and natural resources. At the time of a hearing before
the Chicago Plan Commission, all developments must be in substantial compliance with the
current City of Chicago Sustainable Development Policy set forth by the Housing and
Economic Development. The proposed Plarmed Development shall be in compliance with
the Sustainable Development Policy by obtaining LEED certification and by providing a
green roof of at least 50% of Net Roof Area of the new buildings constructed in Sub-Area A
containing a green roof of 22,961 square feet and shall meet the applicable storm water
requirements of the Department of Planning and Development.
15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning
Ordinance. Should this Planned Development ordinance lapse, the Commissioner of the
Department of Planning and Development shall initiate a Zoning Map Amendment to rezone
the property to the DX-16 Downtown Mixed Use District.
Applicant:
AddressIntroducedPlan Commission

1000 SOUTH MICHIGAN EQUITIES, LLC


920-1006 S. MICHIGAN AVE., 1011-10I5 S. WABASH AVE.
September 24, 2015
TBD

1000 S . Michigan - S . Michigan Avenue | 11th Street | S . Wabash Avenue | 9th Street
PLANNED DEVELOPMENT
BULK REGULATIONS AND DATA TABLE
Sub Area A

Sub Area B

1000 S. Michigan

1006 S. Michigan &

Total

S. Wabash Parcel
Gross Site Area (Net
Site Area + Area in
R.O.W.)

41,884 SF

21,388 SF

63,272 SF

9,545 SF

7,440 SF

16,985 SF

32,339 SF

13,948 SF

46,287 SF

30.29

5.66

22.87

979,497 SF

78,881 SF
(existing)

1,058,378 SF

Maximum Number of
Residential Units

506

Number of Off-Street
Parking Spaces
Provided

586

1 2 (existing)

598

Number of Off-Street
Loading Docks

1 (existing)

Minimum Building
Setbacks

As per Site Plan

None (existing)

Maximum Building
Heigfit

993'

102' (existing)

LEED Certified +
Green Roof

None

Area in Public Right-ofWay

Net Site Area

Maximum Floor Area


Ratio

FAR Area

Green Features

APPLICANT: 1000 S. MICHIGAN AVE. LLC.


ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

JAHN

EXISTING ZONING MAP


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 8. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

SCALE: r=120'-0"

JAHN
COPYRIGHT O JAW. LLC 2015
ALL RIGHTS RESERVED

45

EXISTING LAND USE MAP


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 8. WABASH AVE.
DATE: SEPTEMBER 24, 2015 '
CPC DATE:

90

135

180

SCALE: 1"=18ff-0"

JAHN

36' .1-

99-4"

S. WABASH AVE.

EXISHNG SURFACE PARKING LOT

-EXBTINB Iff PUatre-AttEY

-EXISrMtf-PUBUe-AHBf*^

DdSTING 20 STORT RESIDENTIAL


BUILDING

134-3 3/8"

SITE
SUB

SUHMART
K

GROSS AREA:
RIGHT-OF-WAY:
NET AREA:

41.884 SF
9,545 SF
32.339 SF

TOTAL NET AREA =


(NET AREAS A+B)

46.287 SF

SUB AREA B:
GROSS AREA:
RIGHT-OF-WAY:
NET AREA:

21,388 SF
7,440 SF
13,948 SF

PLANNED DEVELOPMENT BOUNDARY,


PROPERTY LINE AND SUB AREA MAP

APPLICANT: 1000 S. MICHIGAN AVE. LLC,


ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

15

30

45

60

SCALE- r=60'-0'

JAHN

S. WABASH AVE.

o p
Qy
09)
oo
o

SURFACE
"PARKING
LOI FOR
JIQ06 S.
MICHIGAN
(W-SPCSl

EXISTING SURFACE
PARKING LOT
11l'-8"
2 - 3 5/8"

EXISTING
PARK

20'-2 3/8"
^

-V
EASEMENT 4 PAVED VEHICULAR ACCESS

10 PUBLIC ALLEY

COLUMBIA COLLEGE
GETZ THEATER

ti

0.

LLJ

CH
CO

10' PUBLIC ALLf

COLUMBIA
COLLEGE

1014 S.
MICHIGAN

EXISTING 19-STORY
BUILDING

EXISTING
8-STORY
BUILDING

PROPOSED PUBLIC
ART - SEE NOTE #1

1006 S.
MICHIGAN

900 S. MICHIGAN

MICHIGAN AVE.

NOTE:
1. PUBLIC ART SHALL BE PERMITTED BUT NOT REQUIRED. SELECTION OF PIECE AS WELL AS
THE ACQUISITION COST SHALL BE THE RESPONSIBILITY OF THE APPLICANT.
0

SITE PLAN / GROUND FLOOR PLAN


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

15

30

45

60

SCALE: 1"=60'<l"

JAHN

S. WABASH AVE.

oj lo
EXISTING SURFACE
PARKING LOT

EXIST.
rSURFACE
PARKING
LOT

o o

EXISTING
PARK

10' PUBLIC ALLEY


AREAS:
). ROOFTOP GARDEN:
2. HARDSCAPE:
3. GREEN ROOF:
MECH. GREEN ROOF:
MECH. GREEN ROOF:
ROOF TERRACE:
GREEN ROOF:
8. MECHANICAL

COLUMBIA COLLEGE
GETZ THEATER

oc

EXISTING 4
STORV

9.457.4 SF
920.8 SF
6.027.0 SF
1,575.8 SF
2.145.1 SF
2,234.8 SF
3,755.7 SF
928.7 SF
1.920.2 SF
0.

10' PUBLIC ALLEY

CD

COLUMBIA
COLLEGE

EXISTING
4-STORY

1014 s.
MICHIGAN

19-STORY
B-STORT

2flLQl

1006 S. MICHIGAN

1000 S. MICHIGAN

900 S. MICHIGAN

S. MICHIGAN AVE.

GREEN ROOF CALCULATION


A
B
C
D
E
F
G

TOTAL ROOF AREA = SUM (1-9)


lSS ROOF MECHANICAL AREA > -(8+9)
TOTAL NET ROOF AREA = SUM (1-7)
REQUIRED GREEN ROOF AREA (SOX OF NET ROOF)
TOTAL GREEN ROOF PROVIDED = 1+3+4+5+7
TOTAL GREEN ROOF IN EXCESS OF 50% NET ROOF
FAR. BONUS = 9.902.7 / 46,287 X 0.30 X 16

(E-D)

28.965.5 SF
-2,848.9 SF
26.116.6 SF
13.058.3 SF
22.961.0 SF
9.902.7 SF
1.0269

BONUS: 47,532 SF
15

GREEN ROOF AND LANDSCAPE PLAN


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

30

45

60

SCALE r=60'-0-

JAHN

SL

1030'-2"
ROOF TERRACE

gg3'_0"
UNDERSIDE OF UPPERMOST
OCCUPIED FLOOR

9&V-0'

9,

979'-6"
UNDERSIDE OF UPPERMOST
RESIDENTIAL FLOOR SUB

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LQJJ

CONDO
15 FLOORS 11-6" AFF
+3 FLOORS 13-6" AFF

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76B'-0''

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m HI m

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lUUL
ijJLa
CONDO
20 FLOORS 1 1 - 6 " AFF
+1 FLOOR 15'-0" AFF

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liLU

523'-0'
ilLU

3;

mmifi
mju,

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CONDO
20 FLOORS 1 1 - 6 " AFF
+1 FLOOR 15*-0" AFF

illLU

278'-0"
248'-0'

APARTMENTS
11 FLOORS 10'-0" AFF

"o CONDO AMENITIES

"g

148'-0"

ROOFTOP GARDEN
128'-0"

1 1 FLOOR
SHARED AMENITIES

128'-0"

\
PARKING / APARTMENTS
9 FLOORS lO'-O" AFF
+1 FLOOR 13-0" AFF
V7

25'-0"

o
-J,
2

4^

LOBBY / RETAIL

ra

S. MICHIGAN AVE.

S. WABASH AVE.

BUILDING SECTION
APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

SCALE: 1"=110'

JAHN

k/AxllluH HEIGHT
GLASS SCREEN WALL

BALCONIES WITH GLASS RAILS

EXISTING 20 STORY
RESIDENTIAL BUILDING
910 AND 900 s. MICHIGAN

AVE.

EXISTING 4 STORY AND


EXISTING 8 STORY
OFFICE BUILDING
COLUMBIA COLLEGE 1014
AND 1006 s, MICHIGAN AVE,

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PROPOSED
PUBLIC
ART

TOW

11 TH ST.

on no

9TH ST,

EAST ELEVATION - SOUTH MICHIGAN AVENUE


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 8. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE;

SCALE: 1"=B0'

JAHN

GLASS SCREEN WALL"

- CLASS FACADE-

EXISTING 20 STORY
RESIDENTIAL BUILDING
910 AND 900

s. MICHIGAN

AVE. - BEYOND
D
D
0
D

D
0
0
D

0
H
0
B

B
B
B
B

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GUSS FACADEGLASS FACADE-

BALCONIES WITH GLASS RAILS

3T
TRANSLUCENT CLASS FACADE
EXISTING 4 AND 7
STORY BUILDINGCOLUMBIA COLLEGE
62 E. 1ITH ST.
B BBBBBBBBBB B

AND 4 STORY EXISTING


OD
00 00 00 -8OFFI
CE BUILDING
00 DD DO DO
COLUMBIA COLLEGE
00 DD 00 00
1006 s. MICHIGAN AVE.

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PROPOSED
PUBLIC
ART

^
/

CONCRETE/ y
CONCRETE - /
BLOCK PARTY
WALL

[pi] o o o o o [p]

S. MICHIGAN AVE.

WABASH AVE.

SOUTH ELEVATION - EAST 11TH STREET


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 8. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

ELEVATION BEYOND
SCALE: 1"=110'

JAHN

GLASS SCREEN WALL"

i
i

-GLASS FACADE

-BALCONIES WITH GLASS RAILS

EXISTING 20 STORY
RESIDENTIAL BUILDING
910 AND 900 s. MICHIGAN

AVE.

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nnnnnnnnnnnn
nnnnnnnnnnnn
nnnnnnnnnnnn
nnnnnnnnnnnn
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nnnnnnnnnnnn
nnnnnnnnnnnn

-GLASS FACADE

CLASS FAaOE
EXISTING 8 STORY OFFICE
-
BUILDING COLUMBIA COLLEGE
'

1006 s. MICHIGAN AVE. - BEYOND

EXISTING 4 AND 7
- STORY BUILDING
COLUMBIA COLLEGE
62 E. 11TH ST.

11 TH ST.

9TH ST.

WEST ELEVATION SOUTH WABASH AVENUE


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 8. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

SCALE: 1"=110'

JAHN

GLASS SCREEN WALL"

-GLASS FACADE

I n n n n n n n n n n n n n n n n n n [^EXISTING 20 STORY
RESIDENTIAL BUILDING
910 AND 900 s. MICHIGAN

AVE.

-GLASS FACADE

rTRANSLUCENT GLASS FACADE

PROPOSEDPUBLIC
ART

ELEVATION BEYOND

STMICHIGAN AVE.

nnnnnnnnnnnnnnnnnnnn
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NORTH ELEVATION - EAST 9TH STREET


APPLICANT: 1000 S. MICHIGAN AVE. LLC.
ADDRESS: 920-1006 S. MICHIGAN AVE. AND 1011-1015 S. WABASH AVE.
DATE: SEPTEMBER 24, 2015
CPC DATE:

S. WABASH AVE
SCALE: 1"=110'

JAHN

Schuyler
Roche
Crisham

ScHLi-iLER,

RLJDHI;;

&

Two Prudctitial Plaza


180 North Stetson Avenue
Suite 3700
Chicago, Illinois 60601

ATTORNEYS

C R I S H A M ,

P . C

312.565.2400 TEL.
312.565.8300 FAX
SRCatiorueys.com

J O H N J . GEORGE

Attorney at Law
TEL 312 565.8439 FAX 312 565.8300

JGeorqe(S)SRCattornevs.com
September 15, 2015
USPS FIRST CLASS MAIL
In re:

Zoning Amendment and Lakefront Protection Application


920-1006 S. Michigan Ave. and 1011-1015 S. Wabash Ave.
Chicago, Illinois

Dear Property Owner:


In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance and for an
approval under the Lake Michigan and Chicago Lakefront Protection Ordinance, please be informed that
on or about September 15, 2015, I, the undersigned attorney, will file an Application for a change in
zoning from DX-12 and DX-16 Downtown Mixed Use District to the DX-16 Downtown Mixed Use District
and then to a Residential-Business Planned Development and for approval under the Chicago Lakefront
Protection Ordinance on behalf of the Applicant for the property located at 920-1006 S. Michigan Ave.
and 1011-1015 S. Wabash Ave., Chicago, liiinois and bounded by a line 134.28 feet south of and parallel
to East 9th Street; South Michigan Avenue; a line 56.07 feet north of and parallel to East 11th Street; the
alley next west of and parallel to South Michigan Avenue, the alley next north of and parallel to East 11th
Street, the alley next east of and parallel to South Wabash Avenue, a line 99.33 feet north of and parallel
to East 11th Street; South Wabash Avenue; a line 135.40 feet north of and parallel to East 11th Street; a
line 240.94 feet west of and parallel to South Michigan Avenue.
The purpose of the proposed zoning amendment and proposed Chicago Lakefront Protection
Ordinance approval is to permit the construction of 86 story residential tower building with a height of 993'
containing 506 dwelling units, ground floor retail space and 598 accessory parking spaces with the
existing office building to remain.
The Applicant is 1000 South Michigan Equities LLC, whose business address is 55 Fifth Avenue,
New York, New York, 10003. The owners of the property are listed on the reverse side of this letter.
I am the attorney for the Applicant. My address is Schuyler, Roche & Crisham, P.C, 180 N.
Stetson Avenue, Suite 3700, Chicago, Illinois 60601. Please feel free to contact me at (312) 565-8439 if
you should have any questions concerning the Application.
Please note that the Applicant is not seeking to purchase or rezone your property. The Applicant
is required by law to send you this notice because you own property located within 250 feet of the
proposed development.
Very Truly Yours,

/ /
John J. George

SUB-AREA A:
First American Bank, not personally, but as trustee
U/T/A dated April 6, 2009 and known as Trust number 1-09-111
218 West Main Street
West Dundee, IL 60176
Contact: Dawn Griffin
847-403-8109
dgriffin@firstambank.com

SUB-AREA B TENANTS IN COMMON OWNERS:


33'''' Street 1006 Michigan LLC
55 Fifth Avenue, 15"" Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinqer@timeequities.com

RK 2011 Trust 1006 Michigan Avenue LLC


55 Fifth Avenue, 15'^ Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinger@timeequities.com

131 West 33'" 1006 Michigan Avenue, LLC


55 Fifth Avenue, 15"" Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinger@timeequities.com

1006 S Michigan LLC


2 Seaview Blvd.
Port Washington, NY 11050
Contact: Jordan Karlik
516-622-7500
Jordan@jkequities.com

September 15, 2015

Chairman, Chicago Plan Commission


Room 1000 - City Hall
Chicago, Illinois 60602
Re:

Chairman, Conimittee on Zoning


Room 304 - City Hall
Chicago, Illinois 60602

920-1006 S. Michigan Ave. and 1011-1015


S. Wabash Ave., Chicago, Illinois

The undersigned, Chris A. Leach, being first duly sworn, states as follows:
The undersigned certifies that he has complied with the requirements of 17-13-0107 ofthe Chicago
Zoning Ordinance and the requirements of 16-4-100 of Chapter 194B-6.1 of the Lake Michigan
and Chicago Lakefront Protection Ordinance, by sending the attached letter by USPS first class mail
to property owners of the subject property and to property owners of all property within 250 feet of
the property lines of the subject property, excluding public roads, streets, alleys, and other public
ways, up to a maximum of 400 feet including public ways.
The undersigned certifies that the notice contained: the common street address and boundaries of the
subject property; a description of the nature, scope and purpose of the application; the name and
address of the applicant; the date that the applicant intends to file the application; and a source for
additional information on the application and a statement that the applicant intends to file the
application for a change in zoning on approximately September 15, 2015.
The undersigned certifies that he has made a bona fide effort to determine the names and last known
addresses of the persons to be provided with notice by obtaining ownership information from the
most recent authentic tax records of Cook County.
The undersigned certifies that the accompanying list is a complete list containing the names and last
known addresses of the persons provided with notice.
The undersigned certifies compliance with all applicable written notice requirements.

Chris A. Leach
Subscribed and sworn to
before me this September 15, 2015.

Notary Public

CONFIRMATION OF AUTHORITY
TO WHOM IT MAY CONCERN:
The undersigned, 33'" Street 1006 Michigan LLC, 131 West 33'''' 1006 Michigan
Avenue LLC, RK 2011 Trust 1006 Michigan Avenue LLC, and 1006 S Michigan LLC, as
Tenants in Common, are the owners of the property commonly known as 1006 S. Michigan
Avenue, Chicago, Illinois, hereby confirm that the Zoning Applicant, 1000 South Michigan
AvcnurLLC is authorized by the undersigned to file an Application for Amendment to the
Chicago Zoning Ordinance conceming the above-described property.

Dated this K|L day of August, 2015.


PROPERTY OWNERS:
33'" Street 1006 Michigan LLC

131 W9st 33'" 10Q6 Michigan Avenue LLC,


By:

Robert Kantor, a Manager


lobert Kant(5'r,\i^M^nager
RK 2011 T^st 1006 Michigan Avenue LLC
1006 I^Michigan LLC
By:.
iry Karl: p Manager

Robert Kantor, a Manager


By:.

CONFIRMATION OF AUTHORITY

TO WHOM IT MAY CONCERN:

The undersigned, 33'" Street 1006 Michigan LLC, 131 West 33'" 1006 Michigan
Avenue LLC, RK 2011 Trust 1006 Michigan Avenue LLC, and 1006 S Michigan LLC, as
Tenants in Common, are the owners of the property commonly known as 1006 S. Michigan
Avenue, Chicago, Illinois, hereby confirm that the Zoning Applicant, 1000 South Michigan
Avcntte LLC is authorized by the undersigned to file an Application for Amendment to the
Chicago Zoning Ordinance conceming the above-described property.

Dated this Ji(_ day of August, 2015.


PROPERTY OWNERS:
33'" Street 1006 Michigan LLC

131 West 33'" 1006 Michigan Avenue LLC,

By:.

By:.
Robert Kantor, a Manager

RK 2011 Trust 1006 Michigan Avenue LLC

By:
Robert Kantor, a Manager

Robert Kantor, a Manager


1006 SvMichigan LLC

CONFIRMATION OF AUTHORITY
TO WHOM IT MAY CONCERN:

The undersigned. First American Bank^and Tmot,'Trustee under U/T/A dated


April 6, 2009 and known as Trust number 1-09-111, the property owner ofthe property
commonly known as 920-1000 S. Michigan Avenue, Chicago, Illinois, hereby confirms that the
Zoning Applicant, 1000 South Michigan M'enuc LLC is authorized by the undersigned to file an
Application for Amendment to the Chicago Zoning Ordinance conceming the above-described
property. The zoning amendment to the Chicago Zoning Ordinance as authorized herein is
contingent upon the Zoning Applicant acquiring title to the subject property prior to the zoning
amendment ordinance being approved by the Chicago City Council.

lis i i L day of August, 2015.


Dated this

PROPERTY OWNER:

First American Bank^land Trust, 'Tmstee


under U/T/A dated April 6, 2009 and known
as Trust number 1 -09-111

By
Printed Name
Title

Exoneration provision restricting any liability

of First American Bank attached hereto


is expressly made a part hereof.

Exculpation of Trustee
It is expressly understood and agreed by and between the parties hereto,
anything herein to the contrary notwithstanding, that each and all of the warranties,
indemnities, representations, covenants, undertakings and agreements herein made
on the part of the Trustee, while in form purporting to be the warranties, indemnities,
representations, covenants, undertakings and agreements of First American Bank as
said Trustee, are nevertheless each and every one of them, made and intended not as
personal warranties, indemnities, representations, covenants, undertakings and
agreements by First American Bank or any of its directors, officers, employees, or
shareholders or for the purpose or with the intention of binding First American Bank
or any of its directors, officers, employees, or shareholders personally but are made
and intended for the purpose of binding only that portion of the trust property
specifically described herein, and this instrument is executed and delivered by First
American Bank not in its own right, but solely in the exercise of the powers
conferred upon it as such Trustee, and no personal liability or personal responsibility
is assumed by nor shall at any time be asserted or enforceable by any person against
First American Bank or any of its directors, officers, employees, or shareholders on
account of this instrument or on account of any warranty, indemnity, representation,
covenant, undertaking or agreement of the Trustee in this instrument, all such
personal liability, i f any, being expressly waived and released and any recovery
therefor being limited to the property hereby conveyed and the enforcement of
remedies under the documents and instruments creating, securing, or otherwise
governing the obligations secured by this instrument; provided however, this clause
shall not impair the enforceability or adversely affect the availability of any rights
that may otherwise be available to Mortgagee or the obligations of any co-signer,
endorser, or guarantor of the obligations secured by this instrument; and provided
further, that the foregoing limitations on personal liability shall not impair the
validity of the indebtedness secured by Mortgagee's collateral or the lien or security
interest on the collateral or the right of Mortgagee as mortgagee or secured party to
foreclose and/or enforce rights against the collateral after default by the Mortgagor.
Subject to the foregoing, the warranties, indemnities, representations, covenants,
undertakings and agreements herein made on the part of the Tmstee are made for the
sole benefit of Mortgagee, and no other person or persons, other that Mortgagee's
successors or permitted assigns, shall have any benefits, rights, or remedies by reason
of such warranties, indemnities, representations, covenants, undertakings and
agreements herein made on the part ofthe Trustee. Nothing herein shall be deemed
to be a waiver of any right which Mortgagee may have under sections 506(a), 506(b),
1111 (b) or any other provision of the Bankruptcy Refomi Act of 1978, as at any time
amended or reinstated, to file a claim for the full amount of the debt owing to
Mortgagee in the event Mortgagor or its beneficiary should become the subject of a
petition for bankruptcy or reorganization or to require that all collateral shall
continue to secure all ofthe indebtedness owing to Mortgagee in accordance with the
documents and instruments creating, securing, or otherwise governing the obligations
secured by this instrument.

NATIONAL SURVEY SERVICE,


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CITY OF CHIGAGO
APPLICATION FOR AN AMENDMENT TO
THE CHICAGO ZONING ORDINANCE

1.

ADDRESS of the property Applicant is seeking to rezone;


920-1006 S. Michigan Ave, and 1011-1015 S. Wabash Ave.

2.

Ward Niimber that property is located in: 4th Ward

3.

APPLICANT 1000 South Michigan Equities LLC


ADDRESS 55 Fifth Avenue, 15th Floor

CITY New York

STATE NY

PHONE 212-206-6097

ZIP CODE 10003

EMAIL 'singer@tiineequities.com
4.

CONTACT PERSON Robert Singer

Is the applicant the owner of the property? YES


NO X
If the applicant is not the owner of the property, please provide the following information
regarding the owner and attach written authorization from the owner allowing the application to
proceed.
OWNER Please see Exhibit A attached hereto.
ADDRESS
STATE

CITY
ZIP CODE

EMAIL

PHONE.
CONTACT PERSON

If the Applicant/Owner of the property has obtained a lawyer as their representative for the
rezoriing, please provide the followirig information:
ATTORNEY 'Jobn J. George/Chris A. Leach, Schuyler, Roche & Crisham, P.C.
ADDRESS 180 N. Stetson Ave., Suite 3700
CITY Chicago

STATE jL

PHONE (312) 565-8439

FAX (312)565-8300

ZIP CODE 60601


EMAIL jgeorge@srcattorneys.com
cleach@srcattorneys.com

6.

If the applicant is a legal entity (Corporation, LLC, Partnership, etc.) please provide the names
of all owners as disclosed on the'Economic Disclosure Statements.
1000 South Michigan TE! Equities LLC
1000 S Michigan JK Oak LLC

7.

On what date did the owner acquire legal title to the subject property? Various Dates

8.

Has the present owner previously rezoned this property? If yes, when?
No

9.

Present Zoning District DX-12 & DX-16

10.

Lot size,in square feet (or dimensions') 46,287 sq. ft.

11.

Current.Use of the property Office building and surface parking lot.

12.

Reason for rezoning the propertv T redevelop the property with a new residential building while
retaining the existing ofl'ice building.

13.

Describe the proposed use of the property after the rezoning. Indicate the number of dwelling
units; number of parking spaces; approximate square footage of any commercial space; and
height of the proposed building. (BE SPECIFIC)
To permit the construction of a 86 story residential tower building, with a height of 933' containing

Proposed Zoning District DX-16 then to RBPD

506 dwelling units, groundfloorretail space and 598 accessory parking spaces with the existing
office building to remain.
14.

On May l4"\ 2007,, the Chicago City CiDuncil passed the Affordable Requirements Ordinance
(ARO) that requires on-site affordable housing units or a.financial contribution if residential
housing projects receive.a zoning change under certain circuriistances. Based on the lot size of
the project in question and the proposed zoning classification, is this project subject to the
Affordable Requirements Ordinance? (See Fact Sheet for more information)
YESX

NO

COUNTY OF COOK
STATE OF EXINOIS

my

_, being first duly sworn on oath, states that all of the above
statemenjs
and
the
statements
contained
in
the docume^s submitted herewith are true and correct.
nenjs i
South Michigan Equities LLC

Sis

)uth Michigan Manager LLC

Subsoibed and Sworn to before me this


day o f September

. _ , 2015

For Office Use Only

File Number:
Ward:

T L / m r f J j t . Manager
.
KELLEY R. CHAFFEE
Notafy Pubiic. Stats of New Yoifc
NO.01CH632802S
OuaJffied In Nassau County
Commission Expires July 20,2019

Notary Public

Date of Introduction:

fpplicant

ZONING AMENDMENT APPLICATION


EXHBIT A
LIST OF ADDITIONAL PD PROPERTY OWNERS

APPLICANT:

1000 SOUTH MICHIGAN EQUITIES, LLC

ADDRESS:

920-1006 S. Michigan Ave., and 101 1015 S.


Wabash Ave., Chicago, Illinois

SUB-AREA A:
First American Bank, not personally, but as trustee U/T/A dated April 6, 2009 and known
as Trust number 1 -09-111
218 West Main Street
West Dundee, IL 60176
Contact: Dawn Griffin
847-403-8109
dgriffm(^firstambank.com

SUB-AREA B TENANTS IN COMMON OWNERS:


33"^ Street 1006 Michigan LLC
55 Fifth Avenue, 15"" Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinger@,timeequities.com

RK 2011 Trust 1006 Michigan Avenue LLC


55 Fifth Avenue, 15"'Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinger(^timeequities.com

131 West 33'" 1006 Michigan Avenue, LLC


55 Fifth Avenue, 15"^ Floor
New York, New York, 10003
Contact: Robert Singer
212-206-6097
rsinger(^timeequities.com

1006 S Michigan LLC


2 Seaview Blvd.
Port Washington, NY 11050
Contact: Jordan Karlik
516-622-7500
.Jordan(^jkequities.com

CITYOFCHICAGO
ECONO-fVlIC D I S C L O S U R E S T A T E M E N T
AND A F F I D A V I T
S E C T I O N 1 ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
1000 South Michigan Equities LLC '__
Check ONE of the fbllowing three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. Ix] the Applicant
OR
2. [ ] a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party;

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212)206-6097

Fa.x:

Email: rsinger@timeequitles.conri

D. Name of contact person: i^b^rt^j^nger


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
I f the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY

[
[
[
[
[
[
[

1. Indicate the nature ofthe Disclosing Party:


] Person
'
[X] 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:

Illinois

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

[JNo

M N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full names and titles of all executive officers and all directors ofthe entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If
there arc no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing inember,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

1000 South Michigan Manager LLC


1000 South Michigan TEI Equities LLC

Manager
Member

1000 S Michigan JK Oak, LLC

Member

2. Please provide the t^ollowing information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Pauc2of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

1000 South Michigan TEI Equities LLC

55 Fifth Avenue, 15th Floor


New York, New York, 10003

_50%

1000 S Michigan JK Oak LLC

55 Fifth Avenue, 15th Floor


New York, New York. 10003

50%

S E C T I O N 111 -- BUSINESS R E L A T I O N S H I P S WITH C I T Y E L E C T E D O F F I C I A L S


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the
Disclosing Party must cither ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)
^oh^n J George

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Schuyler, Roche &_Crisham^PC _

Attorney

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.
_ $5,000 estimate

180 N Stetson Ave, Suite 3700


-Ghieage-ltiinois 6Q694

(Add sheets if necessary)


[ ] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes

[K] 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?
[]Yes

[]No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for
doing business with the City. .NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I L B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
otTense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concem:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department ofthe Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. 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:
N/A

Patic6of 13

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.
8. 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 12inonth period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is

[K]

is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. Wc understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code: 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
IXiNo
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 . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[]Yes

[]No

3. If you checked "Yes" to Item D . l . , provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of Interest

4. The Disclosing Party further certifies thai 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
_X
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:

S E C T I O N VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 naines of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 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 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 infiuence 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 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.
Paec9of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A. 1. and A.2. above.
4. 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".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[]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 regulations? (See 41 CFR Part 60-2.)
[]Yes
[]No
2. Have you filed with the Joint Reporting Committee, the Director of the OlTice of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2, above, please provide an explanation:

Page 10 of 13

SECTION V I I - - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 arc material inducements to the City's exccutioii
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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.cityofchicaKo.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERM.^NENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee. tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F. i . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
1000 South Michigan Equiti

>ign here)
Robert Kantor

(Print or type name of person signing)


Manager of 1000 South Michigan, LLC, Manager of Disclosing Entity
( P r i n t or type title o f person s i g n i n g )

S i g n e d and s w o r n to before me on (date) (jU>^.^^Uft^ o ? b r ^ / S T


_ County,

(^ate).

Notary Public.
Commission expires:

~J_J^J_LfL.

JOSEPHINE CINOUEMANl
Notary Public, State of New York
No. 4983831
Cii.Rlifiecl ill Bronx County
^
Commission Expires July 8, 2n / /

Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D C I T Y 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under .Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof cufi'ently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as ofthe 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 aldennan, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sLster, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[Xj No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-4)6 of the Municipal
Code?
[ JYes

[XI No

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 Section
2-92-416 ofthe Municipal Code?
[ JYes

[ JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

C I T Y OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I -- G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
1000 S Michigan JK OAK, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ ] the Applicant
OR
2. [X] a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [ ] a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

C. Telephone: 516 622 7500

? SfiaviRw Rivd, in?


Port Washington, NY 11050

Fax: 516 224 7259

Email: jordan@jkequities.com

D. Name of contact person: Jordan Karlik


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
D If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person
[X] 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, i f applicable:

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

[X] No

[ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint ventiu-e, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
J K Equities L L C

Title
Manager

OAK Capitals L L C

Manager

2. Please provide the following information conceming each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

JK Equities L L C - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050 - 50%

OAK Capitals L L C - 1250 S Michigan Ave, #1902, Chicago, I L 60605

50%

SECTION III -- BUSINESS RELATIONSHIPS W I T H C I T Y E L E C T E D O F F I C I A L S


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

[X] No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

SECTION IV ~ D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES


The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets i f necessary)


[X] Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - C E R T I F I C A T I O N S
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ J Yes

[X] 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?
[ J Yes

[]No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in
connection with the Matter, including but not limited to all persons or legal entities disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee ofthe Disclosing Party, any Contractor or any Afflliated 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 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Afflliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Afflliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a " g i f f 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 $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is

[X] is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
'
1. In accordance with Section 2-156-110 of the Municipal Code: 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
[X] No
NOTE: If you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D.l., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes

[] No

3. If you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
tiBia\3^pkiBdng 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 nanies of any and all slaves or slaveholders described in those records:

SECTION VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S


NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 niember of Congress, an officer or employee of Congress, or an employee 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 agreenient, or to extend, continue, renew,
amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
'
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ ] Yes

[X] 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 regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ ] No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION,


C O M P L I A N C E , P E N A L T I E S , DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-1 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent ofthe
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
1000 S Michigan J K
(Print^^drX ype name o^

K, L L C
sclosing Party)

JILRRyKARLIK
(Ffrin^or type name of person signing)
MANAGER OF J K E Q U I T I E S L L C , MANAGER OF DISCLOSING PARTY
(Print or type title of person signing)

Signed and sworn to before me on (date) AU<!^U^f 2-^, Z D ^


at )\(/7Si\\
County, ^iM
Estate).
Notary Public.

KaiEYHCHAFFBS
MolBy PuMe, 8tBts or New Y M
^ i*x01CH6328026
tenmiMian Expires July 20,2O10

Commission expires
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and liniited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[X] No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[ ]No

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I " G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
JK Equities, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party subniitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [J a legal entity with a right of control (see Section I I . B . l . ) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

? SfiaviRw Blvd, lf)2


Port Washington, NY 11050

C. Telephone: 516 622 7500

Fax: 516 224 7259

Email: jordan@jkequities.com

D. Name of contact person: Jordan Karlik


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of prbperty, if applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
D I f the Maftf^r is; a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person
[XJ Limited liability company
Publicly registered business corporation
[ J Limited liability partnership
Privately held business corporation
[ J Joint venture
Sole proprietorship
[ J Not-for-profit corporation
General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership
[ J Yes
[ J No
Trust
[ J Other (please specify)

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

[XJ No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, liniited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing niember,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Jerry Karlik

Title
Manager/Member

Jordan Karlik

Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party
Jerry Karlik - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050

75%

Jordan Karlik - 2 Seaview Blvd #102, Port Washington, NY 11050

25%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such,
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyisf means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[ J Yes

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V ;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defmed in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ 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., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records
of the Disclosing Party and any and all predecessor enthies regarding records of investnients 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
tlBls^3^pkBsdng 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 investnients 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 F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally
funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

. [XJNo

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statenients contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
J K Equities
(Print lor type name /M)isclosing Party)

JiERRY K A R L I K
(Print or type name of person signing)
MANAGER
(Print or type title of person signing)
Signed and sworn to before me pn (date)
at h i ( ' A ^ ^ . L \
County, / j / t ^

U sstate).
t
Notary Public.

..."iMT"'CHAFFEE
Na01O32B028

Commission expires:

Z f i T Q (^

.
Page 12 of 13

02!ffi&Jlt^^|g%,g

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 ofthe date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION 1 ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
OAK Capitals, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [J a legal entity with a right of control (see Section I I . B . l . ) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

i?.sn s Michigan AvpniiR - SiiitR ign?


Chicago, IL 60605

C. Telephone: 312 617 9249

Fax: 844 618 9288

Email: eli@oakcapitals.com

D. Name of contact person: Ellas Abubeker


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
D I f the. Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION 11 ~ DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person
[XJ Limited liability company
Publicly registered business corporation
[ J Limited liability partnership
Privately held business corporation
[ J Joint venture
Sole proprietorship
[ J Not-for-profit corporation
General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership
[ J Yes
[ J No
Trust
[ J Other (please specify)

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

[J No

[XJ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Elias Abubeker

Title
Managing Member

Min Ouyang

Managing Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

Elias Abubeker 1250 S Michigan Ave, #1902, Chicago, IL 60605

50%

Min Ouyang - 1250 S Michigan Ave, #1902, Chicago, I L 60605

50%

SECTION III ~ BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concem:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ 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, proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
docs not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
6Bl^^a^pkIHing 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:

S E C T I O N V I ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ 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 regulations? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (3 12) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing P E R M A N E N T I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1 -23 and Section 2-1 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not Umited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
s, L L C
me of DiscflosSng Party)

(Sign here)
Elias Abubeker
(Print or type name of person signing)
MANAGER O F 1000 S Michigan J K OAK, L L C , MANAGING M E M B E R O F
DISCLOSING PARTY

Signed and sworn to before mc on (date)


at C <z}Cf>c<r
County,
4-^

A'-scs^ 9 7" ) o t ^
(state).
Notary Public.

Commission

expires:

O^/o^//

^_/,>/ ^
Page 12 of 13

OFFICIALSEAL

GUILLERMO D. BUENROSTRO
NOTARY PUBLIC, STATE OF ILLINOIS
My Commission Expires 03-04-2018

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any. person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?

[ J Yes

[XJ No

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

Page 13 of 13

C I T Y 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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

2. I f 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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

F I L L I N G OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS M.\DE IN THIS APPENDIX B ARE
SUBJECT TO T H E CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 O F T H E ASSOCIATED EDS.

C I T Y OF CHICAGO
E C O N O M I C DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
1000 South Michigan TEI Equities LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. ^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 1000 South Michigan Equities LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Departnient of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[KJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Illinois

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

[JNo

^J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors ofthe entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger

^^!H9?I

Robert Kantor

Manager

2. Please provide the following information concerning each person or entity haying a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

Francis Greenburger

55 Fifth Avenue, 15th Floor


New York, New York, 10003

19%

GT Holdings, LLC

55 Fifth Avenue, 15th Floor

76%

RK 2011 Trust

New YoTk, New 7or"R, T00D3


55 Fifth Avenue. 15th Floor

5%

New York, New York, 10003

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND O T H E R RETAINED PARTIES


The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, 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.
"Lobbyist" means any person or entity who undertakes to infiuence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also nieans any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - C E R T I F I C A T I O N S
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[JYes

^J No

[ J N o 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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency: and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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 pr
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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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 govemment, any
state, or any other unit of local govemnient.

3.

The certifications in subparts 3, 4 and 5 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 liinitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirenients of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethiics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
ofthe City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any fime during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

M is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that beconiing a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
EK] No
NOTE: If you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D.l., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. If you checked "Yes" to Item D.I., provide the naines and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will
be acquired by any City official or einployee.
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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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 V I - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section VII. For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f 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 have made lobbying contacts on behalf ofthe
Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any
person or entity to infiuence or attempt to infiuence 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 of a
niember 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 agreenient.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
50'1 (c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section
5011(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following informafion with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[JNo

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulafions? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requireinents?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public 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 infonnation
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. I f 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 Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Departinent of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not liniited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statenients contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
1000 South Michigan TEI Equities LLC

Disc/^osing Party)

Robert Kantor

(Print or type name of person signing)


Manager

(Print or type title of person signing)

Signed and sworn to before me on (date)


at _ i s x ^ ^ j & & ^ _ _ _ County, / t ^

(JLLI^UM

/^As'

(Itate).
Notary Public.

Commission expires:
JOSEPHINE CINnUEMANl

NetBry Public, State of New York


No. 4983831
Qualified in Bronx Co^ui^t^
g^ijimission Expires July 8,

Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 aldennan, the city clerk, the city treasurer or any city departinent 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" nieans (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof cunently
have a "familial relationship" with an elected city official or departinent head?
[ J Yes

[Xj No

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

Page 13 of 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XjNo

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 probleni landlord pursuant to Section
2-92-416 of the Municipal Code?
[ JYes

[ JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
GT Holdings, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2.
a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 131 West 33rd Street 1006 Michigan Avenue,
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II - D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if apphcable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors ofthe entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate orother similar entity. I f none, state "None." NOTE: Pursuantto Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

2003 Francis Greenburger Trust

Percentage Interest in the


Disclosing Party

55 Fifth Avenue, 15th Floor


New York, NY 10003

75%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[Xj No

I f yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to infiuence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 indirecfiy owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person directly or indirecfiy owns 10% or more of the


Disclosing Party.

I f "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?
[JYes

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Arficle I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
idenfified in Secfion I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civil judgment rendered against them in connecfion 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;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with commitfing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any criminal or civil action, including acfions
concerning environmental violations, instituted by the City or by the federal government, any
state, or any other unit of local government.

3.

The certifications in subparts 3, 4 and 5 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, direcfiy 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 organizafion of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorizafion of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

;d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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-rotafing in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

I f 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 INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 acfivities 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. 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 organizafion described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanafion:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 connecfion 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transacfions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime the City takes action on the Matter. I f 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 Arficle I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the informafion provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent ofthe
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all
certifications and statenients contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
GT Holdings, LLC

(Print or tjme name of Disclos

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

Signcyd a M s w o f n to before me onidate)


at JyC^lUlC

Gounty, j n f ^ f j C \C _

M f llLMA
u

fi'f^

V^

4=

^
(itate).

Notary Pubiig'.ry FuWic, Stete of New Yc

-p-

^ . No.02V!6131(M0
Qi'allt5sd in .iJew Yo.'fc Courrt'

Commission expires:

| /

'

Page 12 of 13

/ J

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy has a "famihal 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 execufive officers of the Disclosing Party listed in Secfion H.B.l.a., i f the
Disclosing Party is a corporafion; all partners of the Disclosing Party, i f the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[JYes

IxJNo

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

Page 13 of 13

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 percent (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 Municipal Code Secfion 2-154-010, is the Applicant or any Owner idenfified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XjNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ GENERAL INFORMATION
A. Legal name.of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
2003 Francis Greenburger Trust
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitfing this EDS is:
1. [ J the Applicant
OR
2. [x] a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 131 West 33rd Street 1006 Michigan Avenue,
OR
3. [ J a legal entity with a right of control (see Secfion II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Idenfificafion No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I - D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[ J Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full names and titles of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar enfities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Wilmington Trust Company

Title
Trustee

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

Isabelle Greenburger
Noah Greenburger
Claim Greenburger
Julia Greenburger
Morgan Greenburger

55 Fifth Avenue, 15th Floor, New York. NY 10003


55 Fifth Avenue, 15th Floor, New York, NY 10003
55 Fiflli Avenue, 15th-Floor, New Yoik, NY 10003
55 Fifth Avenue, 15th Floor, New York, NY 10003
55 Fifth Avenue, 15th Floor, New York, NY 10003

Beneficiary
Beneficiary
Beneficiaiy
Beneficiary
Beneficiary

S E C T I O N I I I - BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJNo

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or entity other than: (1) a not-for-profit enfity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrafive action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10%) or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person direcfiy or indirecfiy 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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or enfities
idenfified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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 anfitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental enfity (federal,
state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an adniission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating.in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed oh any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. 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 of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

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 statenients.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Ycs
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 cither 1. or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N V I - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f 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 have made lobbying contacts on behalf of the
Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in Paragraph A. I . above for his or her lobbying activifies or to pay any
person or entity to influence or attempt to infiuence 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in secfion
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion
501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activifies".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain cerfifications 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
durafion of the Matter and must make such certifications prompfiy available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirenients?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 connecfion 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 acfion 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f the City determines that any informafion 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 parficipate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By complefing 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 informafion submitted
in this EDS.
E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime 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 Arficle I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the informafion provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entifies delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking fickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Enfities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
2003 Francis Greenburger Trust

(Print or tp^pe name of


By:

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)


Signed and sworn to before mc pn (date) i ^ ^ K ) ^
at /l/fU Y^^i^-j
County, /^CWYOATC-(slate).
li I L i l . \ U f i K
//UXM-^'
fj
r
Commission expires:

vW'-^

~^

--jyrubli^SteteorNUvYc,;
NotaryPublic. No.02V!6131040
Qi-'alrfjeti in New Yo* Count , -j
\I .
Page 12 of 13

'

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as ofthe 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 Secfion n.B.i.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and liniited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
RK 2011 Trust
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is;
1. [ J the Applicant
OR
2. [x] a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: RK 2011 Trust 1006 Michigan Avenue LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212)206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specificafion #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[ J Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entifies, the state (or foreign country) of incorporafion or organization, if applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal fitleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal enfity listed below must submit an EDS on its own behalf
Name

Title

Francis Greenburger

Trustee

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informafion
from any applicant which is reasonably intended to achieve full disclosure.

Jane Kantor
David Becker

Percentage Interest in the


Disclosing Party
55 Fifth Avenue, 15th Floor, New York, NY 10003
Beneficiary
55 Fifth Avenue, 15th Floor, New York, NY 10003
Beneficiary

Bryan Becker
Elizabeth Katz

55 Fifth Avenue, 15th Floor, New York, NY 10003


55 Fifth Avenue, 15th Floor, New York, NY 10003

Name

Business Address

Beneficiary
Beneficiary

S E C T I O N I I I - BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?

[ J Yes

[Xj No

If yes, please identify below the name(s) of such City elected official(s) and describe such
rclationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the
Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person directly or indirecfiy 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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a confinuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS;
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental enfity (federal,
state or local) with commitfing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connecfion 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreenient to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by'the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to cerfify to any of the above statements in this Part B (Further
Cerfifications), the Disclosing Party must explain below;
N/A

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. 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 of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

W is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

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 statenients.
D. CERTIFICATION REGARDING INTEREST I N CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Docs any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D . L , provide the names and business addresses of the City
officials or employees having such interest and idenfify the nature of such interest:
Name

Business Address

Nature of 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 cither 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N VI ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Secfion V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 ariy 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either; (i) it is not an organization described in secfion
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organizafion described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain cerfifications 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


I f the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulations? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporfing Conimittee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanafion:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public 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 informafion submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of
Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F. 1. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.
NOTE; I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
RK 2011 Trust

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me on (date)


at IVrv/ / O Z - K Coupty, / I V W Y D V - ^

'state).
-Gtary F ufjirc. State of New Yc
NotaryPublic.^ No. 02VI6131040
QcaliffstJ in New Yorit Cbun^

Commission expires;
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 "famihal relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the
Disclosing Party is a corporafion; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the 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 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domesfic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IxJ No

If yes, please idenfify below (1) the name and tifie of such person, (2) the name of the legal enfity 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 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITYOFCHICAGO
ECONO.MIC D I S C L O S U R E S T A T E M E N T
AND A F F I D A V I T
S E C T I O N 1 - G E N E R A L INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
1000 South Michigan Manager, LLC

Check ONE of the following three boxes:


Indicate whether the Disclosing Party submitting this EDS is;
1. [ J the Applicant
OR
2. [ J a legal enfity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest;
OR
3.
a legal entity with a right of control (see Section II.B.l.) State the legal name ofthe entity in
which the Disclosing Party holds a right of control: J.009A9y*JlJ^.i.?.^J9^1^11'^^
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: 12.12) 206-6097

Fax:

Email: isin^ger@tirneequities.c^^

D. Name of contact person: Robert Singer


E. Federal Employer Idenfification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which fiiis EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

vor. 01-01-12

_ and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E OF OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
\)Q Limited liability company
[ J Person
[ J Limited liability partnership
[ J Publicly registered business corporation
[ J Joint venture
[ J Privately held business corporation
[ J Not-for-profit corporation
[ J Sole proprietorship
(Is the not-for-profit corporation also a 501(c)(3))?
[ J General partnership
[JYes
[JNo
[ J Limited partnership
[ J Other (please specify)
[J Trust

2.

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Illinois

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

[JNo

[Xj N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If
there arc no such members, write "no members," For trusts, estates or other similar entities, list below
the legal titlcholdcr(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE; Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

Jerry Karlik
'"EIias"A5'ubee7' "

Manager
Manager""

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a paitnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve l^uU disclosure.
Name
Francis Greenburger
Robert Kantor
Jerry Karlik
Elias Abubeker

Percentage Interest in the


Disclosing Party

Business Address
55 Fifth Avenue, 15th Floor
New York, New York, 10003
55 Fifth Avenue. 15th Floor
New York, New York, 10003
55 Fifth Avenue, 15th Floor
New York, New York. 10003
55 Fifth Avenue, 15th Floor
"T^FvTYorirWw'Y'orRTToB'OS"

41%
8%
25%
25%

S E C T I O N 111 - BUSINESS R E L A T I O N S H I P S WITH C I T Y E L E C T E D O F F I C I A L S


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

M No

If yes,'please identify below the namc(s) of such City elected official(s) and describe such
relationship(s);

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who arc paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to infiuence any legislative or administrative
acfion on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself "Lobbyist" also means any person or entity any part of whose dufies as an employee of
another includes undertaking to infiuence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Section, the
Di.sclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[JYes

[KJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter I -23, Article I ("Article l")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Pat;c4of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons orentities
identified in Section I L B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

arc 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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transacfions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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 enfities disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, tho 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 of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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
governinent or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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 5/33 E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further
Certifications), the Disclosing Party must explain below;
N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[KJ is

not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. Wc further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. Wc understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-1 10 ofthe Municipal Code: Docs any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
M No
NOTE: If you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. If you checked "No" to
Item D.l., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNO

3. If you checked "Ycs" to Item D. 1., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the MaUcr 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connecfion with the Matter voidable by the City.
X
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 conducfing 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:

S E C T I O N VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the .Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 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 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 infiuence 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 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 cooperafive agreement.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. 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".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[JNO

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (Sec 41 CFR Part 60-2.)
[ J Ycs
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirenients?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J NO
li'you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII - A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that;
A. 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 arc 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligafions on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.cityofchicago.ortj/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
othervv'ise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The 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. I f the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party inust
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that;
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor arc the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, t^cc, tax or other charge owed to tho City. This includes, but is not limited to, all water charges,
sewer charges, license iocs, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A, on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that docs not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.
NOTE; I f the Disclosing Party cannot certify as to any of the items in F. 1., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
1000 South Michigan Manager, LLC

(Print f r type nam^pTDidfclosing Party)

Robert Kantor

(Print or type name of person signing)


Manager of 1000 South Michigan, LLC, Manager of Disclosing Entity
( P r i n t o r type title o f person s i g n i n g )

Signed and sworn to before mc on (date)


J ^ A d sL^pJ^aoJL** ,
at __L4<v:^j!J5[_..__.._ County, A 4 ^ _ ' ^ 4 r - ^ ^ , (stato),^
_ Notary Public.
C{/Timission expires;

2v

JOSFPHIME CIMQUEMANI
Notary Public, Statf? ot New York

No, iPfjasai

Oi.'alififid in Bronx County ^


Commission Expires July 8, 20 / ' |

Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIXA

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 Parhicr thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, fathcr-in-law, mother-in-law, son-in-law, daughtcr-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 Di.sclosing Party listed in Secfion II.B.l.a., if the
Disclosing Party is a corporafion; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members 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 percent ownership interest in the Disclosing Party. "Principal officers" moans the president, chief
operafing ofticer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domesfic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[JYes

[XjNo

If yes, please idenfify below (1) the name and tifie of such person, (2) the name of the legal enfity 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
I

jYes

|X|No

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 scoffiaw or problem landlord pursuant to Section
2-92-416 ofthe Municipal Code?
[ JYes

[ JNo

(xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
1006 S Michigan, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [XJ the Property Owner
OR
2. [J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [ J a legal entity with a right of control (see Section I I . B . l . ) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

2 SRavlfiw Blvd. 102


Port Washington, NY 11050

C. Telephone: 516 622 7500

Fax: 516 224 7259

Email: jordan@jkequlties.com

D. Name of contact person: Jordan Karlik


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP I N T E R E S T S


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ ] Joint venture
[ J 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, i f applicable:

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

[J No

[] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Jerry Karlik

Title
Manager

Elias Abubeker

Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party
JK 1006 S MICHIGAN L L C - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050 - 50%

OAKS CAPITAL L L C - 1250 S MICHIGAN AVE #1902 CHICAGO, I L 60605

50%

SECTION III ~ BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than; (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrafive action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that cbntract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[ J Yes

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Arficle I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V ;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certificafions in subparts 3, 4 and 5 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, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation;
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorizafion of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospecfive bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ 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., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[] No

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest;
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
tHisvSs^pkradng 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 - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S


N O T E : I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary); _

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 meniber of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and inforrnation set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ 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 regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any
contract or other agreenient 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, inipose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. If the City determines that any informafion 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent ofthe
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
1006 S MICHIGAN L1.C
(PripTor type name oC^isclosing Party)

ign h
JyERRY KARLIK
int or type name of person signing)
MANAGER
(Print or type title of person signing)
Signed and sworn to before me on (date)Mj^fLiji
at N d ^ S ^ i U
County, k J ^
(state).

UTIOIS

Notary Public
J l
^
S-^.
, - r , y / n f \ IPtSa
Commission expires: ^ J l U i / / i J , U J r i
^
/
^''^^ '
'

. KElIEyR. CHAFFEE
i*i"iy PubHc, state of New Yak
^Jto.01CH6328028
-QuaBfled In Nassau County
mfniasionE>ipiiTnJu|y2Q,ioi9
Page 12 of 13

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" 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 adopfion: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

If yes, please identify below (1) the name and tifie 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I ~ GENERAL INFORMATION
A. Legal name of the Disclosing Party subniitting this EDS. Include d/b/a/ if applicable:
JK 1006 S Michigan, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

2 Reavlfiw Rlvrl, in?


Port Washington, NY 11050

C. Telephone: 516 622 7500

Fax: 516 224 7259

Email: jordan@jkequitles.com

D. Name of contact person: Jordan Karlik


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
D If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
'
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party;

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Liniited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, i f applicable:

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

[XJNo

[JN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full nanies and tifies of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entifies, list below
the legal titleholder(s).
I f the entity is a general partnership, liniited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Jerry Karlik

Title
Manager

Michael Siemer

Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party
JK Equities 1006 L L C - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050 - 25%

1006 Mich Office, L L C -111 E Wacker Drive, #900 Chicago, IL 60601

75%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or enfity other than; (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relafionship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) N O T E :
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets i f necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entifies that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

'

[XJ No

[ J No person direcfiy or indirecfiy 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?

[JYes

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transacfions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary); _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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?
[ J Yes
[XJ No
NOTE: If you checked "Yes" to Item D.l., proceed to Items D.2. and D.3. If you checked "No" to
Itern D.l., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
tiBis\3^pkiKlng 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 F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally
funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[XJNo

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Intemet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. N O T E : With respect to Matters subject to Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing P E R M A N E N T I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page I I of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
JK 1006 S MICHIGAN L L C
(Print or Jy^e name of disclosing Party)

JERRY K A R L I K
(Priof or type name of person signing)
MANAGER
(Print or type title of person signing)

Signed
and swori
sworn to before me on (date) /I\A ^l/jJ"^ ^ ^ OltJ
signed and
/state).
at
County,, N j y j
Notary Public.
Commission
iissTon expires
Page 12 of 13

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
JK Equities 1006, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section I I . B . l . ) State the legal name of the enfity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

2 Reaview Rlvd, 102


Port Washington, NY 11050

C. Telephone: 516 622 7500

Fax: 516 224 7259

Email: jordan@jkequities.com

D. Name of contact person: Jordan Karlik


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
D If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F O W N E R S H I P I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Liniited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporafion
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, i f applicable:

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

[XJ No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full nanies and titles of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
I f the entity is a general partnership, limited partnership, limited liability company, liniited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
N O T E : Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

J K Equities L L C

Manager/Class B Member

Sikelele Investment Holdings L P

Class A Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Parly. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar enfity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party
JK Equities L L C - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050 - 90%

Sikelele Investment Holdings, LP, 6015 Yorkville Court, Dallas, TX 75248

10%

SECTION III ~ BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
.not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligafions by any Illinois court of competent jurisdiction?

[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V ;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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 organizafion of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislafive Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-1 56 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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?
[JYes
[XJNo
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., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.I., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
tftsvSa^pkredng 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 ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S


N O T E : I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary);

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 meniber of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulafions 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?
[ J Yes

[XJ 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 regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable'filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f the City determines that any informafion 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a
contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. N O T E : With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing P E R M A N E N T I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking fickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
J K Equities 1006 L L C
(Print or type naine of Disclo;
By:

JERRY KARI^K
(Print or type name of person signing)
MANAGER OF J K EQUITIES L L C , MANAGER OF DISCLOSING PARTY
(Print or type title of person signing)

Signed and sworn to before me on (date)


at AAh^-S^V^ /7 / ^ n t v , / ^ ( ^ j o M ^ (state).
Notary Public.
.ommission expires
Page 12 of 13

MICHAEL K BEETLE
Notary PuUic - State of New York
NO. 01BE6097425
Qualified in Suffolk County
My Commlailon Eipirei Aup 18.2019

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Secfion 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operafing officer, executive director, chieffinancialofficer, treasurer or secretary of a legal enfity 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?

[ J Yes

[XJ No

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

Page 13 of 13

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 Apphcant, and (b) any legal entity
which has a direct ownership interest in the Applicant exceeding 7.5 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Sikelele Investment Holdings, LP
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Secfion II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

6015 Ynrkville Court


Dallas, TX 75248

C. Telephone: 972 248 8510

Fax: 972 248 7845 ,

Email: rosenbloom.brian@gmail.com

D. Name of contact person: Brian Rosenbloom


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Department of Planning and Development
E) If the Matter i; a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
Indicate the nature of the Disclosing Party:
[ J Person
[J Limited liability company
[ J Publicly registered business corporation
[ J Limited liability partnership
[ J Privately held business corporation
[ J Joint venture
[ J Sole proprietorship
[ J Not-for-profit corporation
[ J General partnership
(Is the not-for-profit corporafion also a 501(c)(3))?
[XJ Limited partnership
[ J Yes
[ J No
[J Trust
[ J Other (please specify)

2. For legal entifies, the state (or foreign country) of incorporation or organization, if applicable:
Texas

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

[XJ No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and tifie of each general partner, managing member,
manager or any other person or enfity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Tifie

Brian Rosenbloom

Manager/General Partner

Howard Kraines
NKOSI Management Group L L C

Limited Partner
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Brian Rosenbloom
_Howard Kraines

Business Address

Percentage Interest in the


Disclosing Party

6015 Yorkville Court, Dallas, TX 75248


6018 Rose Grove Court, Dallas, TX 75248

NKOSI Management Group LLC 6015 Yorkville Court, Dallas, TX 75248

49.5%
49.5%
1%

SECTION III - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 jurisdicfion?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a confinuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal enfity, all of those persons or enfities
identified in Section II.B.l. of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged gijilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding 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.

3. The certifications in subparts 3, 4 and 5 concern:


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connecfion 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislafive Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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?
[ J Yes
[XJ 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., proceed to PartE.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records
ofthe 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
tilavDs^pkiKlng 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 F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf ofthe 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 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 enfity listed in Paragraph A . l . above for his or her lobbying acfivifies or to pay any
person or enfity 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 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 cooperafive agreement, or to extend, continue, renew,
amend, or modify any federally funded contract, grant, loan, or cooperative agreement.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certificafions for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


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

[ J Yes

[XJ 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 regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause? .
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 acfion 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.
B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 parficipafion in the Matter and/or
declining to allow the Disclosing Party to participate in other transacfions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public 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 connecfion with the public release of informafion
contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted
in this EDS.
E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime 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 Arficle 1 of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the informafion provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and^Q0mjjIeteas of the dalFfomisiied to the City.
Sikelele Investment Holdings LP
(Print or type name of Disclosing Party)
By:
(Sign here)
Brian Rosenbloom
(Print or type name of person signing)
MEMBER OF JK EQUITIES 1006 L L C , MANAGER OF DISCLOSING PARTY
(Print or type title of person signing)

Signed and sworn to before me on (date)


at ( x ) X U y n ^
County, ^ J 2 ^ L \ S

(state).
Notary Public.

Commission expires:
Page 12 of 13

LISA BEACH
My Commission Expires
August 21, 2017

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporafion; all partners oftiieDisclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[X] No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
Nkosi Management Group, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

6015 Ynrkviiie Court


Dallas, TX 75248

C. Telephone: 972 248 8510

Fax: 972 248 7845

Email: rosenbloom.brian@gmail com

D. Name of contact person: Brian Rosenbloom


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this EDS?Pepartment of Planning and Development
P If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ J Person
[XJ Limited liability company
[ J Publicly registered business corporation
[ J Limited liability partnership
[ J Privately held business corporation
[ J Joint venture
[ J Sole proprietorship
[ J Not-for-profit corporation
[ J General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
[J Limited partnership
[ J Yes
[ J No
[ ] Trust
[ J Other (please specify)

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

[XJ No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all execufive officers and all directors of the enfity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or enfity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Brian Rosenbloom

Tifie
Sole Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar enfity. If none, state "None." NOTE: Pursuantto Secfion 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such addifional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Brian Rosenbloom

Business Address

Percentage Interest in the


Disclosing Party

6015 Yorkville Court, Dallas, TX 75248

100%

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relafionship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the
Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligafions 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 jurisdicfion?
[ ] Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[ J Yes

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person 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 confinuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
fimeframe in Article I supersedes some five-year compliance timeframes in certificafions 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal enfity, all of those persons or entities
identified in Section II.B.l. of this EDS:
. a.

are not presenfiy debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from any transacfions by any federal, state or local unit of government;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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 violafion of federal or state antitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;
c.

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 clause B.2.b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding 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.

3. The certifications in subparts 3, 4 and 5 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 enfity that, direcfiy 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; idenfity of interests among family members, shared facilities
and equipment; common use of employees; or organizafion of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirecfiy controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorizafion of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Enfity of either the Disclosing Party
or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years
before the date of such Contractor's or Affiliated Enfity'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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to cerfify to any ofthe above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary): _
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE: If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D.I., proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[J No

3. If you checked "Yes" to Item D.l., provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
ttts\3^pkiHing 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 F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 enfities registered under the federal Lobbying
Disclosure Act of 1995 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 enfities
registered under the Lobbying Disclosure Act of 1995 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated cerfification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and informafion set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party cerfifies that either: (i) it is not an organizafion described in secfion
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[XJNo

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you parficipated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanafion:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that;
A. 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 connecfion with the Matter, whether
procurement, City assistance, or other City acfion, and are material inducements to the City's execution
of any contract or taking other acfion 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 parficipate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response tb 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 connecfion with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any ofthe items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certificafierrs^d staterfferrts-CQntained in this EDS and Appendix A (if applicable) are true, accurate
complete as of the date fumisltbd^to the City.
Nkosi Management Group, L L C
JPrint or type name of Disclosing Pa
By:
(Sign here)
Brian Rosenbloom
(Print or type name of person signing)
MANAGER OF S I K E L E L E INVESTMENT HOLDINGS LP , SOLE MEMBER OF
DISCLOSING PARTY

Signed and ^worn to before me on (date) _


at
County,

(state).

o o

^
Page 12 of 13

mm

LISA BEACH
My Commission Expires
August 21, 2017

Notary Public.
Commission expires: - A X V ^ ^ \ ^ T ^ H

wm

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" with
any elected city official or department head. A "familial relationship" exists if, as ofthe 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.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

If yes, please identify below (I) the name and tifie of such person, (2) the name of the legal enfity 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 relafionship.

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
1006 Mich Office, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [J the Property Owner
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B. 1.) State the legal name of the entity in
which the Disclosing Party holds a right of control;
B. Business address of the Disclosing Party:

111 F Wanksr DrivR #gnn


Chicago, IL 60601

C. Telephone: 312 819 4444

Fax; 312 819 5410

Email: msiemer@bradleyassoc.com

D. Name of contact person: Mike Siemer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash
G. Which City agency or department is requesting this EDS?Department of Planning and Development
I f the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature ofthe Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[JYes
[JNo
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Delaware
3. For legal entities not organized in the State of Illinois; Has the organization registered to do
business in the State of Illinois as a foreign entity?
[XJ Yes

[J No

[J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
I f the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
MHSR L L C C/O Michael Siemer

Title
Manager

SNJL L L C C/O Sherwin Jarol

Manager

BMJ Investment Holdings L L C c/o Bradley Jarol


VJP Management L L C c/o Luke Jacob Pascale

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

MHSR L L C

Percentage Interest in the


Disclosing Party
111 E W A C K E R D R I V E #900 C H I C A G O I L 60601
40%

SNJL L L C

111 E W A C K E R D R I V E #900 C H I C A G O I L 60601

40%

BMJ Investment Holdings L L C 111 E Wacker Drive #900 Chicago I L 60601 15%
S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclpse
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to infiuence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for
doing business with the City. NOTE: If Article 1 applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial insfitution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE: I f you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X I . 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
tfts\3^plKlng 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:

S E C T I O N VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I . List below the names of all persons or enfities registered under the federal Lobbying
Disclosure Act of 1995 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ 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 regulations? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous.contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certificafions, 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 acfion, 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-1 54-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
1006 Mich Office L L C
(Print or type name of Disclosing Party)
By:
(Sign here)
M I C H A E L SIEMER
(Print or type name of person signing)
MANAGER OF MHSR L L C , MANAGER OF DISCLOSING PARTY
(Print or type title of person signing)

Signed and sworn to before me on (date) j-^ [J


at 0.60k.
County, |||inT>I .S
^ate).
Notary Public.
Commission expires:
Page 12 of 13

AlliSONrMNO
NOTARY PUBUC - STATE OF ttXiNOIS

mi

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

If yes, please identify below (I) 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

C I T Y OF C H I C A G O
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
MHSR, LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [J the Property Owner
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party;

111 F Wanker nrivR #flnn


Chicago, IL 60601

C. Telephone: 312 819 4444

Fax; 312 819 5410

Email: msiemer@bradleyassoc.com

D. Name of contact person: Mike Siemer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash
G. Which City agency or department is requesting this EDS?Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party;

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

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

[J No

[J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Michael Siemer

Tifie
Sole Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Michael Siemer

Business Address

Percentage Interest in the


Disclosing Party
U l E W A C K E R D R I V E #900 C H I C A G O I L 60601
100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[JYes

[XJNo

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 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;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code; Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE: I f you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
ttts^3^ptolI^ng 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:

S E C T I O N VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f 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 enfities
registered under the Lobbying Disclosure Act of 1995 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 ofticer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ No

I f "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
I f you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that;
A. The certificafions, 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 acfion, 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 terminafing the Disclosing Party's participation in the Matter and/or
declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parfies List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
MHSR, L L C
(Print or type name of Disclosing Party)
By:
(Sign here)
M I C H A E L SIEMER
(Print or type name of person signing)
Sole Member
(Print or type title of person signing)

Signed and sworn to before me on (date)


at O o o f l County, | ( l i n t l l ' ^
M

< \ . i < i U j h

Commission expires:

Jslate>.
Notary Public.

1^
p

IO f iQ

i-ageizOT l i

AUJiSOWtKWG

(^TARY PUBUC-STATE OF lUlNOiS

'*T1T'TTrsag8Sflgfl3/i9

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Apphcant, and (b) any legal entity which has a direct
ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 ofthe 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., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;
SNJL, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [J the Property Owner
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name ofthe entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

111 F Wanker Drive #9nn


Chicago, IL 60601

C. Telephone: 312 819 4444

Fax; 312 819 5410

Email: sjarol@bradleyassoc.com

D. Name of contact person: Sherwin Jarol


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash
G. Which City agency or department is requesting this EDS?Department of Planning and Development
I f the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page I of 13

__

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
I.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[JYes
[JNo
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Delaware
3. For legal entifies not organized in the State of Illinois: Has the organization registered to do
business in the State of Illinois as a foreign entity?
[XJ Yes

[J No

[J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and titles of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
I f the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Sherwin Jarol

Sole Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Sherwin Jarol

Business Address

Percentage Interest in the


Disclosing Party

111 E W A C K E R D R I V E #900 C H I C A G O I L 60601

100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

I f yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N I V ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: ( I ) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE; I f Article I applies to the Applicant, the permanent compliance
timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B. 1. of this EDS;
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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 entifies disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Secfion 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-1 10 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
BlisvDs^pkmlng 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;

S E C T I O N VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 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 i f the letters "NA" or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501 (c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certificafions for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ 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 regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certificafions, 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-1 56 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarcerafion and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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. N O T E : With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
SNJL L L C
(Print or type na
By:
(Sign here)
Sherwin Jarol
(Print or type name of person signing)
Sole Member
(Print or type title of person signing)

Signed and sworn to before me on (date) f V O l ) i ^ ' \ ^ | ^


County, l l l l l O I It g.
i f c )
(Jate).
at

(^'OlO

Notary Public.
NOTARY PUBUC-I
fOWBITIOtI

Commission expires:
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Apphcant, and (b) any legal entity which has a direct
ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 execufive officers ofthe Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all pnncipal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

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

Page 13 of 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Apphcant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ GENERAL INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
BMJ Investment Holdings, LLC

Check ONE ofthe following three boxes:


Indicate whether the Disclosing Party submitting this EDS is:
1. [J the Property Owner
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control;
B. Business address of the Disclosing Party:

111 F War.ker nrivp #Qnn

Chicago, IL 60601

C. Telephone: 312 819 4444

Fax: 312 819 5410

Email: bjarol@bradleyassoc.com

D. Name of contact person: Sherwin Jarol


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash
G. Which City agency or department is requesting this EDS?Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[JYes
[JNo
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Delavyare
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?
[XJ Yes

[J No

[J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Bradley Jarol

Sole Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE; Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Bradley Jarol

Business Address

Percentage Interest in the


Disclosing Party

111 E W A C K E R D R I V E #900 C H I C A G O I L 60601

100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 jurisdicfion?
[ J Yes

[XJ No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitfing this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

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 clause B.2.b. of this Section V ;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 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;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement.to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

I f 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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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?
[JYes
[XJNo
NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D. I . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
tlliB\3^pkKlng 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:

S E C T I O N V I - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f 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 have made lobbying contacts on behalf ofthe
Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined by
applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a
meniber 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


I f the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ No

I f "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulafions? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation;

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that;
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Enfities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F. I . , F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
BMJ Investment Holdings L L C
(Print or type name of Displesing Rarfy)

(Sign here)
Bradley Jarol
(Print or type name of person signing)
Sole Member
(Print or type title of person signing)
Signed and sworn to before me on (date)
at
County, l i l l i n n i S

^(stale).
Notary Public.

Commission expires:
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 (I) all executive officers of the Disclosing Party listed in Section II.B. 1 .a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?

[ J Yes

[XJ No

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

Page 13 ot 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ G E N E R A L INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable:
VJP Management, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is;
1. [J the Property Owner
OR
2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name
of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

111 F Wanker Drive #Qnn


Chicago, IL 60601

C. Telephone: 312 819 4444

Fax: 312 819 5410

Email: jake@bradleyassoc.com

D. Name of contact person: Luke Jacob Pascale


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash

G. Which City agency or department is requesting this EDS?Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N II - D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature ofthe Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[XJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of Incorporation or organization, if applicable:

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

[J No

[] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name
Luke Jacob Pascale

Tifie
Sole Member

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a meniber or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Luke Jacob Pascale

Business Address

Percentage Interest in the


Disclosing Party

111 E W A C K E R D R I V E #900 C H I C A G O I L 60601

100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to infiuence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
I f 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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

N/A

(Add sheets if necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[JYes

[XJNo

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

I f "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

B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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;

c.

afe 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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (I) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislafive Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official, of
the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

[XJ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in theMoss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

. I f 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 INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code: 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?
[JYes
[XJNo
NOTE: I f you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , 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 namie 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?
[JYes

[JNo

3. If you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 I . or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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
filisvBs^pkraJng 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:

S E C T I O N V I ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[XJ 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 regulafions? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 acfion, 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.I.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot cerfify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: ( I ) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
VJP Managment L L C
(Print or type name of Disotasing Party)
By:

Luke Jacob Pascale


(Print or type name of person signing)
Sole Member
(Print or type title of person signing)

Signed and sworn to before me on (date) /j|/fl|/<.{"f" / ^ ^ / ^ Q


at P. 00 l l ^
County, [ [ l i n p i S> ^(state).
Notary Public.
Commission expires;

j ^ ^
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

[XJ No

If yes, please identify below (I) the name and fitle 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.

''A.
Page 13 of 13

'

*-''^-v'-^.*. vv:..<^.,-*,^...>

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 scoffiaw or problem landlord pursuant to Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT T H E REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO T H E CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I - G E N E R A L INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;
RK 2011 Trust 1006 Michigan Avenue LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1 EK] the Owner of property located at 1006 South Michigan Avenue
OR
2. [J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [ J a legal entity with a right of control (see Secfion II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control;
B. Business address of the Disclosing Party;

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone; (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
I.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Illinois

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

[ J No

[xJ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full nanies and tifies of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a niember or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

RK2011 Trust

Percentage Interest in the


Disclosing Party

55 Fifth Avenue, 15th Floor


New York, NY 10003

100%

S E C T I O N III - BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[xJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or esfimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[Xj Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 indirecfiy owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[ J No

^J No person directly or indirecfiy 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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitfing this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a confinuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with commitfing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any criminal or civil action, including acfions
concerning environmental violations, instituted by the City or by the federal government, any
state, or any other unit of local government.

3.

The certifications in subparts 3, 4 and 5 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 enfity that, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business enfity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospecfive 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

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certificafions), the Disclosing Party must explain below:
N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9, To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any fime during the
12-month period preceding the execufion date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party cerfifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensafion 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?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and idenfify the nature of such interest;
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
I . 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:

S E C T I O N V I - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter; (Add sheets i f necessary):

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f the word "None"
appear, it will be conclusively presumed that the Disclosing Party means that NO persons or enfities
registered under the Lobbying Disclosure Act of 1995 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. 1. above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined by
applicable federal law, a member of Congress, an officer or employee of Congress, or an employee 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 agreenient.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. 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) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activifies".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications prompfiy available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


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

[ J Yes

[ J No

I f "Yes," answer the three questions below;


1. Have you developed and do you have on file affirmative acfion programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question I . or 2. above, please provide an explanafion:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certificafions, 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. .
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a
contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of
Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page I I of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
RK 2011 Trust 1006 Michigan Avenue LLC

(Print orftype narne of Disclosing Party)

(Sign here)

(Print or type name of person signing)

(Print or type fitle of person signing)

Signed and sworn to before me-pn (date) / / l ^ t^S


at M v IJ/^ i ^ County, m ^ J W ^ j C (state).
iiiCHAfvU'VlEiiji

f i T

^'Clary Fublic, Stale of New Yo

NotaryPublic^

No. 02VI6131C40

Qualifisd in New Yo* County

Commission expires; v

J ^ '^"'^1. ~^

.
Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domesfic Partner thereof currenfiy has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Secfion 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
131 West 33rd 1006 Michigan Avenue, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. ^ the Owner of property located at 1006 South Michigan Avenue
OR
2. [J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party;

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone; (212) 206-6097

Fax:

Email; rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
I.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporafion
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organizafion, if applicable:

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

[ J No

[xJ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors ofthe entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing meniber,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE; Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

131 West 33rd Street Holdings, LLC

Percentage Interest in the


Disclosing Party

55 Fifth Avenue, 15th Floor


New York, NY 10003

100%

S E C T I O N III - BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[xJ No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or entity other than: (1) a not-for-profit enfity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the
Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


[Xj Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligafions throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

[ J No

^J No person directly or indirecfiy 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

[JNo

B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitfing this EDS is the Applicant and is doing business with the City, then the Disclosing Party
cerfifies as follows: (i) neither the Applicant nor any controlling person 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 confinuing requirement for
doing business with the City. NOTE; I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in cerfificafions 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
identified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorizafion of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Enfity of either the Disclosing Party
or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nafionals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to cerfify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

I f 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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
ofthe City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, ofthe City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institufion" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that beconiing a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Secfion 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D . L , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collecfively,
"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?
[ J Yes

[ J No

3. If you checked "Yes" to Item D . l . , provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest;
Name

Business Address

Nature of 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 I . or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connecfion with the Matter voidable by the City.
X
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:

S E C T I O N VI ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf ofthe Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A. 1. and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion 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".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' cerfifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


I f the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[JNo

I f "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmafive action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 connecfion 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transacfions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f the City determines that any informafion 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 terminafing the Disclosing Party's participafion in the Matter and/or
declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The informafion 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 Arficle I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-1 54-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Enfities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
131 West 33rd Street 1006 Michigan Avenue, LLC
(Print or type name of Diisclosing Party)
By:
(Sign here)

g e g g ^ y:4^>^(^
(Print or type name of person signing)

(Print or type title of person signing)

Signed and sworn to before me an (date) j N h P j ^ \


at / V f V f ^ A t l
Ceunty, J y J U h rX-(state).

/
Commission expires;

/)

XI t
D , , . --i20fFu!jlic State Of New Yo;.'^
NotaryPublic.
No. 02VI6131040
Qi "aliiied in New York County/^

Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., i f the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Docs 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?
[ J Yes

[xJ No

If yes, please identify below (1) the name and tifie of such person, (2) the name ofthe legal entity to which
such person is connected; (3) the name and tifie 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;
131 West 33rd Street Holdings, LLC
Check ONE of the following three boxes;
Indicate whether the Disclosing Party submitting this EDS is;
1. [ J the Applicant
OR
2. ^ a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 131 West 33rd Street 1006 Michigan Avenue,
OR
3. [ J a legal entity with a right of control (see Secfion II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone; (212)206-6097

Fax;

Email: rslnger@tlmeequitles.com

D. Name of contact person; Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or"other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party;

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporafion
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and tifies of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

Francis Greenburger

55 Fifth Avenue, 15th Floor


New York, NY 10003

25%

GT Holdings, LLC

55 Fifth Avenue, 15th Floor


New York, NY 10003

75%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[Xj No

I f yes, please idenfify below the name(s) of such City elected official(s) and describe such
relationship(s);

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" nieans any person or enfity who undertakes to influence any legislafive or administrafive
acfion on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the
Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?

[ J Yes

^J No

[ J No person directly or indirecfiy owns 10% or more of the


Disclosing Party.

I f "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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirenients), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entifies
idenfified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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 anfitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statenients; or receiving stolen property;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3,

The certifications in subparts 3, 4 and 5 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, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorizafion of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of compefition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nafionals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. I f the Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 fime during the 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges;

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code; Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[XJ No
NOTE; I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competifive 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"). Conipensation 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?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 I . or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
I . 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 consfitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

S E C T I O N V I - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section. V I I . For purposes of this Section V I , 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 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 i f the letters "NA" or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


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

[ J Yes

[ J 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 regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporfing 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
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 execufion
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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime 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 Arficle I of
Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
131 West 33rd Street Holdings, LLC

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

led and sworn


Signed
swor to before me Qnj-(da-te)
mMjIirlCfoum-,.
W W Yu/iClfslate).

Commission expires; U l M ^

'2^0 I

N otary Publ,lfc{ary Fufjiic. State of New Yo


No.02V!6131040
I
QL;aHfisd in New York County

'

Page 12 of 13

" IT

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D C I T Y 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relafionship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

If yes, please identify below (1) the name and tifie of such person, (2) the name of the legal enfity 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION 1 ~ G E N E R A L INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;
33rd Street 1006 Michigan Avenue, LLC
Check ONE ofthe following three boxes:
Indicate whether the Disclosing Party submitfing this EDS is:
1. ^ the Owner of property located at 1006 South Michigan Avenue
OR
2. [J a legal enfity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control;

B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequitles.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
I.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Liniited liability partnership
[ J Joint venture
[ J Not-for-profit corporafion
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Illinois

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

[ J No

[xJ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar enfities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE; Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Secfion 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

33rd Street Holdings, LLC

55 Fifth Avenue, 15th Floor


New York, NY 10003

Percentage Interest in the


Disclosing Party
100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[JYes

[xJNo

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount ofthe fees paid or esfimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than; (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the
Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[XJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entifies.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[JYes

[ J No

^J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE; I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities
idenfified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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 violafion of federal or state antitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with commitfing any ofthe offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any criminal or civil acfion, including actions
concerning environmental violations, instituted by the City or by the federal government, any
state, br any other unit of local government.

3.

The certifications in subparts 3, 4 and 5 concem:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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
violafion of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certificafions), the Disclosing Party must explain below:
N/A

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges;

"We are not and vvill not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes'

[JNo

3. I f you checked "Yes" to Item D.L, provide the nanies and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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 investnients 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:

S E C T I O N VI ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 acfivifies 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statenients and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in secfion
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulafions? (See 41 CFR Part 60-2.)
[JYes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to question 1. or 2. above, please provide an explanafion:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any
contract or other agreenient 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article 1 of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Departnient of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
cerfifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
33rd Street 1006 Michigan Avenue, LLC

(Print or type name pf Disclosing Party)

(Sign here)

(Print or type name of person signing)

(Print or type fitle of person signing)

Signed and sworn to before me pn (dale) ^ I M I A ^ V


at \ J i \ J ^ ^ f \ L County, | v f V j 7 6 r ^ " (state).
Notary Public.
/

7 ( ^

Commission expires; L/ V S ^

, 7

I / .
Page 12 of 13

i'^iCHAROViEST
f-ictary Public, State of New Yorr
N0.02VI6131C40
Qualified in New York County ; -j

Ccnvv.ission Expires Juiy ?.5,20 f_ /

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" 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.l .a., if the
Disclosing Party is a corporafion; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the 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 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

If yes, please idenfify 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 13

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 percent (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 Municipal Code Secfion 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;
33rd Street Holdings, LLC
Check ONE ofthe following three boxes;
Indicate whether the Disclosing Party submitfing this EDS is:
1. [ J the Applicant
OR
2.
a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC
OR
3. [J a legal enfity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
^
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax;

Email: rslnger@timeequities.com

D. Name of contact person; Robert Singer


E. Federal Employer Identificafion No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesfing this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[JNo
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the enfity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporafion, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE; Pursuant to Secfion 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informafion
from any applicant which is reasonably intended to achieve full disclosure.
Name
West Willows Equities, LLC

Business Address
55 Fifth Avenue, 15th Floor

Percentage Interest in the


Disclosing Party
100%

New York, NY 10003

S E C T I O N 111 ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJNo

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or enfity other than: (1) a not-for-profit enfity, on an unpaid basis, or (2)
himself. "Lobbyist" also nieans any person or enfity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entifies.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
cerfifies as follows; (i) neither the Applicant nor any controlling person is currenfiy 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 con.spiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B. I . of this EDS:
a.

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;

b.

have not, within a five-year period preceding 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 anfitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with commitfing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that direcfiy 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 of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collecfively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospecfive bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospecfive bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of ( I ) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below;
N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code; Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D.L, provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Parly checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N VI - C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 entifies registered under the federal Lobbying
Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter; (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in secfion
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in secfion
501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
durafion of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


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

[ J Yes

[ J 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 regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporfing 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
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that;
A. The cerfifications, 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page I I of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entifies delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
33rd Street Holdings, LLC

(Sign here)

(Print or type name of person signing)

AAP^f><3^-^
(Print or type tifie of person signing)

Signed ^rid swprn to before me on (d-ate)


at f^f U Ar 1^
County,
fJfU /O rV_((tate).

'

Notary Publiectafy Public, State of New Yor:Y'l

Commission expires._

<^
Page 12 of 13

N0.02VI6131C40

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all execufive officers ofthe Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporafion; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domesfic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

If yes, please idenfify below (1) the name and title of such person, (2) the name of the legal enfity 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 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
West Willow Equities, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitfing this EDS is:
1. [ J the Applicant
OR
2. \x\ a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control;
B. Business address of the Disclosing Party;

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one):
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
I f the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Ver. 01-0M2

and Contract #

Page 1 of 13

S E C T I O N I I - D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party;

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal enfities, the state (or foreign country) of incorporation or organization, i f applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors of the enfity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Secfion 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Park Place Equities, LLC

Business Address

Percentage Interest in the


Disclosing Party

55 Fifth Avenue, 15th Floor


New York, NY 10003

100%

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[Xj No

I f yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, 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.
"Lobbyist" nieans any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or entity other than; (1) a not-for-profit enfity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose dufies as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

M No

[ J No person directly or indirecfiy owns 10% or more ofthe


Disclosing Party.

I f "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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
idenfified in Section I I . B . l . of this EDS;
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment rendered against them in connecfion 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;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with commitfing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any criminal or civil acfion, including actions
concerning environmental violations, instituted by the City or by the federal government, any
state, or any other unit of local government.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospecfive bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statements.
8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all current employees of the Disclosing Party who were, at any time during the 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Secfion 2-32-455(b) ofthe Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj 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, proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. If you checked "Yes" to Item D.L, provide the nanies and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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 investnients 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:

S E C T I O N V I - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City
and proceeds of debt obligations ofthe City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING
I . List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter; (Add sheets i f necessary):

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f 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 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 meniber of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in secfion
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organizafion described in section
501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activifies".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J No

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmafive action programs pursuant to applicable
federal regulafions? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question I . or 2. above, please provide an explanafion;

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 arc 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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
decHning to allow the Disclosing Party to participate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be
made available to the public 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 informafion
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a
contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.
NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
West Willow Equities, LLC
(Print or^ype name of E\isclos|pg Parlj
By:__
(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

Signed arrd/sworn to before rnaon^date),


at ( \ f ( U / ^ H ^ C o u i v t v , f 7 / K j D r / t -

(slate).
NotaryPublic.

Commission expires: U ( ^ ^ 1 J ^ T - ^ 1 ^

Page 12 of 13

'
-

,
^
^

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Secfion 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy has a "familial relationship" with
any elected city official or department head. A "famihal relationship" exists if, as ofthe 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 (I) all executive officers ofthe Disclosing Party listed in Section II.B.l .a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
parmership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal enfity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO T H E CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
S E C T I O N I - G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
Park Place Equities, LLC
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is;
1. [ J the Applicant
OR
2. Dd a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212)206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
Publicly registered business corporafion
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[xJ Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

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

MNo

[JN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and tifies of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal fitleholder(s).
I f the entity is a general partnership, limited partnership, liniited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar enfity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Rupertsland Holdings, lnc


New Regime Co, LP

Percentage Interest in the


Disclosing Party
55 Fifth Avenue, 15th Floor, New York, NY 10003
14.89%
55 Fifth Avenue, 15th Floor, New York, NY 10003
16.11%

Robert Kantor
Francis Greenburger

55 Fifth Avenue, 15th Floor, New York, NY 10003


55 Fifth Avenue, 15th Floor, New York, NY 10003

10.55%
29.53%

S E C T I O N I I I ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[Xj No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or enfity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
I f 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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or esfimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[Xj Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person directly or indirectly owns 10% or more ofthe


Disclosing Party.

I f "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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
fimeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Secfion I I . B . l . of this EDS;
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

are not presently indicted for, or criminally or civilly charged by, a governmental enfity (federal,
state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Enfity of either the Disclosing Party
or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the fiye 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 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;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors; the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Enfity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively
presumed that the Disclosing Party cerfified to the above statenients.
8, 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-nionth period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Secfion 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code; Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D . L , proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

[JNo

3. I f you checked "Yes" to Item D . l . , provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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 conducfing 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;

S E C T I O N V I ~ C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf ofthe Disclosing Party with
respect to the Matter; (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None"
appear, it will be conclusively presumed that the Disclosing Party nieans that NO persons or entities
registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf ofthe
Disclosing Party with respect to the Matter.)
2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined by
applicable federal law, a meinber of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statenients and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that cither; (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[JYes

[J'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 regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation;

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 acfion 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f the City determines that any informafion 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public 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 informafion submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the fime the City takes action on the Matter. I f 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 Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parfies List System ("EPLS") maintained by the U. S. General Services Administrafion.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any
contractors/subcontractors hired or to be hired in connection with the Matter certificafions equal in
form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.
NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
Park Place Equities, LLQ
(Print or tvpo\nam
By:

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

(date) fi^Ml- ItZ^f^

Signed and sworn to before me on


at /i/iJjOjrJL_
Qounty,
/lAwViy^fC

'
^
Commission expires;

(Jtate).

Notary Publj9.p,;S|stet8 0fNewY^


I I
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' N0.02VI6131C40
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7 0 / /
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Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Apphcant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption; parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currenfiy
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

If yes, please identify below (1) the name and tifie of such person, (2) the name ofthe legal enfity 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 relafionship, and (4) the precise nature of such familial relationship.

Page 13 of 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I ~ G E N E R A L INFORMATION
A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:
Rupertsland Holdings, lnc
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. ^ a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC
OR
3. [ J a legal entity with a right of control (see Section II.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party;

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email; rsinger@timeequlties.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one);
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Vcr. 01-01-12

and Contract #

Page 1 of 13

S E C T I O N I I ~ D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature ofthe Disclosing Party;

Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[ J Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Ycs
[ J No
[ J Other (please specify)

For legal entifies, the state (or foreign country) of incorporation or organization, if applicable:

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

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and fifies of all execufive officers and all directors of the enfity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal fifieholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a niember or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informafion
from any applicant which is reasonably intended to achieve full disclosure.
Name
Francis Greenburger

Business Address

Percentage Interest in the


Disclosing Party

55 Fifth Avenue, 15th Floor


New York, NY 10003

14.89%

,_

S E C T I O N III ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[Xj No

I f yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s);

S E C T I O N IV - D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or enfity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislafive or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[xJ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or enfifies.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

^J No

[ J No person directly or indirectly owns 10% or more ofthe


Disclosing Party.

I f "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

[JNo

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirenient for
doing business with the City. NOTE; I f Article I applies to the Applicant, the permanent compliance
timeframe in Arficle I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal enfity, all of those persons or entities
idenfified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment rendered against them in connection with;
obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or
contract under a public transacfion; a violation of federal or state anfitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transacfions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any criminal or civil action, including acfions
concerning environmental violations, instituted by the City or by the federal government, any
state, or any other unit of local government.

3.

The certifications in subparts 3, 4 and 5 concern:

the Disclosing Party;


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

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, 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-rotafing in
violafion of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department ofthe Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any ofthe above statements in this Part B (Further
Certifications), the Disclosing Party must explain below;
N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institufion" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N V I ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organizafion described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' cerfifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


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

[JYes

[JNo

If "Yes," answer the three questions below;


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ J Yes
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanafion:

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, I L 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U . S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
Rupertsland Holdings, lnc

(Print or t^pe name off Disclosing Party)

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

Signe(L^nd>^wornj tp before ma on (^atc) ,


at
ounty,
M M ^ I y } ^
Commission

expires;

(state).
Nou,ry Public,

"

(
Page 12 of 13

, . ^ & S T ^ ^ o . ^ ,

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D C I T Y OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Apphcant, and (b) any legal entity which has a direct
ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 relafionship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the
Disclosing Party is a corporafion; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and menibers of the 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 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

If yes, please idenfify 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 13

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 percent (an "Owner").
It is not to be completed by any legal entity which has only an indirect ownership interest in
the Applicant.
1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified asa
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND A F F I D A V I T
SECTION I - G E N E R A L INFORMATION
A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable;
New Regime Co. LP
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. [ J the Applicant
OR
2. M a legal entity holding a direct or indirect interest in the Owner
. State the legal name of the
Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC
OR
3. [ J a legal enfity with a right of control (see Section II.B.l.) State the legal name ofthe entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

55 Fifth Avenue, 15th Floor


New York, New York, 10003

C. Telephone: (212) 206-6097

Fax:

Email: rsinger@timeequities.com

D. Name of contact person: Robert Singer


E. Federal Employer Identification No. (if you have one); .
F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, i f applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Vcr. 01-01-12

and Contract #

Page I of 13

S E C T I O N II - D I S C L O S U R E O F OWNERSHIP I N T E R E S T S
A. NATURE OF THE DISCLOSING PARTY
1.

Indicate the nature of the Disclosing Party:

Person
,
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust

2.

[ J Limited liability company


[ J Limited liability partnership
[ J Joint venture
[ J Not-for-profit corporation
(Is the not-for-profit corporation also a 501(c)(3))?
[ J Yes
[ J No
[ J Other (please specify)

For legal entities, the state (or foreign country) of incorporation or organization, i f applicable:

New York
3. For legal enfities not organized in the State of Illinois: Has the organizafion registered to do
business in the State of Illinois as a foreign entity?
[ J Yes

M No

[ J N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;


1. List below the full names and titles of all executive officers and all directors of the entity.
N O T E : For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal fitleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Tifie

Francis Greenburger
Robert Kantor

Manager
Manager

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporafion, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. I f none, state "None." NOTE; Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional informafion
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party
55 Fifth Avenue, 15th Floor, New York, NY 10003

Lillian Jaffe Trust


RKP Revocable Declaration of Trust
Eil^pn Westbaum
Patricia and Thomas Carren

55 Fifth Avenue, 15th Floor, New York, NY 10003


55 Fifth Avenu** 15th Floor New York NY 10003
55 Fifth Avenue, 15th Floor, New York, NY 10003

Uebra Chwast Kevocable 1 rust


Jeffrey Newmark
Johnathan Newmark Living Trust

bb Fifth Avenue, Ibth Floor, New York, NY 1U003


55 Fifth Avenue, 15th Floor, New York, NY 10003
55 Fifth Avenue, 15th Floor, New York, NY 10003

3.54%
1.77%
2 65%
2.65%
2.6b%
1.33%
1.33%

S E C T I O N I I I ~ BUSINESS R E L A T I O N S H I P S W I T H C I T Y E L E C T E D O F F I C I A L S
Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 of the Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ J Yes

[XJNo

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):

S E C T I O N IV ~ D I S C L O S U R E O F S U B C O N T R A C T O R S AND O T H E R R E T A I N E D P A R T I E S
The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
acfion on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) N O T E :
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


[Xj Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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 jurisdicfion?
[JYes

^J No

[ J No person directly or indirecfiy 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?
[ J Yes

[JNo

B. FURTHER CERTIFICATIONS
I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance.with Article 1 is a confinuing requirement for
doing business with the City. NOTE; I f Article I applies to the Applicant, the permanent compliance
timeframe in Arficle I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
idenfified in Section I I . B . l . of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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 violafion of federal or state antitrust statutes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;

c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3.

The certifications in subparts 3, 4 and 5 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, direcfiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation;
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management,,ownership7or 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 of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Cerfifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

^J is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee
of the City have a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
[Xj No
NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to
Item D.L, proceed to Part E.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensafion 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?
[ J Yes

[ J No

3. I f you checked "Yes" to Item D.L, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest;
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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:

S E C T I O N V I ~ C E R T I F I C A T I O N S F O R F E D E R A L L Y FUNDED M A T T E R S
NOTE: I f the Matter is federally funded, complete this Secfion V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter: (Add sheets if necessary);

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f 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 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 enfity listed in Paragraph A . l . above for his or her lobbying acfivifies or to pay any
person or enfity 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in secfion
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".
5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulations? (See 41 CFR Part 60-2.)
[ J Yes .
[ J No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[JYes
[JNo
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ J No
If you checked "No" to quesfion I . or 2. above, please provide an explanation;

Page 10 of 13

S E C T I O N VII ~ A C K N O W L E D G M E N T S , C O N T R A C T I N C O R P O R A T I O N ,
COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 execufion
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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document avafiable to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By complefing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. N O T E : With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
I f the Disclosing Party is the Applicant, the Disclosing Party wifi obtain from any
contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in
form and substance to those in F.l. and F.2. above and will not, without the prior written consent ofthe
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any of the items in F.l., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as of the date furnished to the City.
New Regime Co. LP

(Print or type name of Disclosing Party)

(Sign here)

(Print or type name of person signing)

(Print or type title of person signing)

ckte) J^j^iiWrr^oif
UA\L(date).

Commission expires

l
/

>7

Notary Public, 'c^sty Fublic, State of NsvvYo


N0.02VI6131C40
N0.02V!6131M0
1 o
'?;>aIirradinNewYo.'kC0ort' ,

Page 12 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D C I T Y 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with
any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Secfion II.B.l.a., if the
Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partaership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domesfic Partner thereof currenfiy
have a "familial relationship" with an elected city official or department head?
[ J Yes

IXJ No

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

Page 13 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIXB
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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ JYes

[XJNo

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 Section
2-92-416 of the Municipal Code?
[JYes

[JNo

[xJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
R E F E R E N C E INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO T H E CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

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:
First American Bank, not personally, but as Trustee U/T/A dated April 6, 2009 ahd known as Trust numbfer 1-09-111.
Check ONE of the following three boxes:
Indicate whether the Disclosing Party submitting this EDS is:
1. M the Property Owner
OR
2. [ J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the
Applicant in which the Disclosing Party holds an interest:
OR
3. [ J a legal entity with a right of control (see Section ILB.l.) State the legal name ofthe entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

C. Telephone: (847)403-8109

?IR wp^t Main strpst. Wpst niinrifip>. liiinnis Rniia

Fax: (847)403-8109

Email: dgnffin@flr5tambank.com

D. Name of contact person: Dawn Griffin


E. Federal Employer Identification No. (if you have one):,

_^

F, Brief descripfion of contract, transaction oi sither undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabasli.

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver. 01-01-12
DM2\605629S,I

and Contract #

Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OFTHE DISCLOSING PARTY
I. Indicalc llie nature of tlic Di,sclosing i'lirty:
I I'crson
[ ] Limited liability company
] Publicly registered business corporation
[ ] Limited liability partnership
] Privately held business corporation
[ ] Joint venture
1 Sole proprietorship
f ] Not-for-profit corporation
I General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
] Limited partnership
[ ] Yes
[ ] No
[x] Trust
[ J Other (please specify)

2.

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
Illinois

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

[ 1 No

[X] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal litleholder(s). First American Bank is the Tmstee of Trust # 1-09-111.
If the entity is a general partnership, limited partnership, limited liability company, limited liabiUty
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE; Each legal entity listed below must submit an EDS on its own behalf.
Name
lana Naqpil

Title
Fypir.utlva Vine Prfislrient

Dawn Griffin

Senior Vice President

Beverly C. Hayes

Vice President

Rosanne M, DuPass

Vice President

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7,5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a hmited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None;" NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

A m A r i r a n R p a l FstatR InvRstmsnts N n P, I I C, 7 0 0 Rriggp RnaH, Flk G r n v p VillagR, II

mCiViJ

i n n % hPHpfirlal IntArpgt

SECTION 111 ~ BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll,
"Lobbyist" m.eans any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attorney,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add shcet.s if necessary)


1X1 Check here if the Disclosing Party has not retained, nor expects lo retain, any such persons or entities.
SECTION V ~ CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

M 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?
[ ] Yes

[ ] No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consiiU for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Apphcant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for
doing business with the City. NOTE: If Article I applies to the Apphcant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
'
;
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;

c.

are not presently indicted for, or criminally or civiUy charged by, a governmental entity (federal,
state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding 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.
3. The certifications in subparts 3, 4 and 5 concern:
the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in
connection with the Matter, including but not hmited 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: contrpls 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 mterests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affihated Entity or any
other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither the Disclosing Party
or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 ov 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;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or
c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following hsts
maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List,
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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.
8. To the best of the 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient,
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)
I

[ ] is

^] is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2. If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code, We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the Municipal Code: 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
M 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., 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 tho 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?
[JYes

MNo

3. If you checked "Yes" to Item D.l., provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest;
Name

Business Address

Nature of Interest

4. The Displosing Party further certifies that no prohibited financial interest in the Matter will
be acquired by ^ny City official or employee.
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS
Please check either 1. or 2. below. If-thc Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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: I f the Matter is federally funded, complete this Section VL If the Matter Is not federally
funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City
and proceeds of debt obligations of the City arc 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 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification al the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that cither: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make .such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


I

If the Matter is federally funded, federal regulations require the Apphcant 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?
[JYes

[jNo

If "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[]Yes
[JNo
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract CompUanee Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
[ ] No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ J Yes
[ ] No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION V n - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:

',

A. The certifications, disclosures, and acknowledgrrients 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 Parly's participation in the Matter and/or
declining to allow the Disclosing Party to participate in other transactions with the City, 'Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the pubhc on its Internet site and/or upon
request. Some or all ofthe information provided on this EDS and^any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. I f 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 Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibihty must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code,
The Disclosing Party represents and warrants that:
i

Page 11 of 13

6
F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, lax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
I f the Disclosing Party is the Applicant, the Djsclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F . l . and F.2. above and will nol, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: If the Disclosing Party cannot certify as to any ofthe items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if apphcable) are ti-ue, accurate
and complete as of the date furnished to the City.
First American Bank, not personally, but as Trustee U/T/A dated April 6, 2009 and known as Trust number 1-09-111
(Print or type name of Disclosing Party)

By: P(jLuM/V
(Sign here)
Exoneration provision restricting any lisbility
(Print or type name of person signing)

of First American Bank attached hereto


is expressly made a part hereof.

Senior- Vice P r e s i d e n t
(Print or type title of person signing)

Signed and swom to before me on (date)


a'
/{/^/^(f
County^
Illinois

(state).
Notary Public.

Commission exp ires:

f((/o/Ct
IS-

QFRCIM.SEAL
RdSMMEOUPASS
Page 12 of 13

DM2\6056296.1

NOTAWWBUC-CTATEOFiaiMOIS
MY COMMSSJON EXPIRES:! 1/04/18

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICULS 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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code 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 "famihal relationship" with
any elected city official or department head. A "familial relationship" exists if, as ofthe date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Apphcable Party" means (1) all executive officers ofthe Disclosing Party hsted in Section ILB.l.a., if the
Disclosing Party is a corporation; all partners of tlie Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited
partnership; all managers, managing members and members ofthe Disclosing Party, i f 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 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?
[ ] Yes

^ ] No

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 famihal relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13

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 percent (an "Owner").
It is not to be completed by any legal entity wliich has only nn indirect ownership interest in
the Applicant.
1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
1
[ .JYes

[X]No

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 Section
2-92-416 ofthe Municipal Code?
[ JYes

( JNo

[XJ Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, TPIE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

Exculpation of Trustee
It is expressly understood and agreed by and between the parties hereto,
anything herein to the contrary notwithstanding, that each and all ofthe warranties,
indemnities, representations, covenants, undertakings and agreements herein made
on the part of the Trustee, while in form purporting to be the warranties, indemnities,
representations, covenants, undertakings and agreements of First American Bank as
said Trustee, are nevertheless each and every one of them, made and intended not as
personal warranties, indemnities, representations, covenants, undertakings and
agreements by First American Bank or any of its directors, officers, employees, or
shareholders or for the purpose or with the intention of binding First American Bank
or any of its directors, officers, employees, or shareholders personally but are made
and intended for the purpose of binding only that portion of the trust property
specifically described herein, and this instrument is executed and delivered by First
American Bank not in its own right, but solely in the exercise of the powers
conferred upon it as such Trustee, and no personal liability or personal responsibility
is assumed by nor shall at any time be asserted or enforceable by any person against
First American Bank or any of its directors, officers, employees, or shareholders on
account of this instrument or on account of any warranty, indemnity, representation,
covenant, undertaking or agreement of the Trustee in this instrument, all such
personal liability, i f any, being expressly waived and released and any recovery
therefor being limited to the property hereby conveyed and the enforcement of
remedies under the documents and instruments creating, securing, or otherwise
governing the obligations secured by this instrument; provided however, this clause
shall not impair the enforceability or adversely affect the availability of any rights
that may otherwise be available to Mortgagee or the obligations of any co-signer,
endorser, or guarantor of the obligations secured by this instrument; and provided
further, that the foregoing limitations on personal liability shall not impair the
validity of the indebtedness secured by Mortgagee's collateral or the lien or security
interest on the collateral or the right of Mortgagee as mortgagee or secured party to
foreclose and/or enforce rights against the collateral after default by the Mortgagor.
Subject to the foregoing, the warranties, indemnities, representations, covenants,
undertakings and agreements herein made on the part of the Trustee are made for the
sole benefit of Mortgagee, and no other person or persons, other that Mortgagee's
successors or permitted assigns, shall have any benefits, rights, or remedies by reason
of such warranties, indemnities, representations, covenants, undertakings and
agreements herein made on the part of the Trustee. Nothing herein shall be deemed
to be a waiver of any right which Mortgagee may have under sections 506(a), 506(b),
1111 (b) or any other provision of the Bankruptcy Reform Act of 1978, as at any time
amended or reinstated, to file a claim for the full amount of the debt owing to
Mortgagee in the event Mortgagor or its beneficiary should become the subject of a
petition for bankruptcy or reorganization or to require that all collateral shall
continue to secure all of the indebtedness owing to Mortgagee in accordance with the
documents and instruments creating, securing, or otherwise governing the obligations
secured by this instrument.

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I ~ GENERAL LNFORMATION
A. Legal name of the Disclosing Party submitting this EDS, Include'd/b/a/ if applicable;
American Real Estate Investments No, 2, LLC
Check ONE of the following three boxes;
Indicate whether the Disclosing Party submitting this BDS is:
1. [ J the
OR

2. [xl a legal entity holding a direct or indirect interest in. the Property Owner. State the.legal name of thfe
Applicant in which the Disclosing Party holds an interest; First American Bank, not personally, but aa
. OR
Trustee U/T/A dated April 6,2009 and known aa Trust No. 1-09-lU
3. [J alegalentity with a right of control (see Section ILB.L) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B. Business address of the Disclosing Party:

C. Telephone;

847-586-2583

D. Name of contact person;

Fax;

7nn Riissfi R^H nk nrmn yiiiaQft, iiiinnte Roop?

847-586-2583

Donald Roubitchek

Eftail; droubitchek@firstanibank.com
^_

E. Federal Employer Identification No. (if you have one):


F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South IVIIchlgan Avenue and 1011-1015 South Wabash.
G. Which City agency or department is requesting this BDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following;
Specification #

Ver. 01-01-n
DM2\6066331.1

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature ofthe Disclosing Party: ,
Person
,
,
^J Limited liability company
Publicly registered business corporation
[ J Limited liability partnership
Privately held business corporation
[ J Joint venture
Sole proprietorship
[ J Not-for-profit corporation
General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership
[ J Yes
[ J No
Trust
[ J Other (please specify)

2.

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:
Illinois

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

[ J No

[X] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


:

1. List below the full names and titles of all executive officers and all directors ofthe entity.
NOTE: For not-for-profit corporatiojis, also list below all members, if any, which are legal entities. I f
there are no such members, write "no inembers." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE: Each legal entity hsted below must submit an EDS on its own behalf.
Name

Title

_ J i r s t American.Bank

Sole Member and Managfir

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
I

Page 2 of 13

interest of a member or manager in a hmited hability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None," NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Flr.qt AmRfinan Rank

Business Address

Percentage Interest in the


Disclosing Party

16.^0 I mil.'; Avp.., Flk firnvft Village, II Rpnn/

100% a.q snle mpmhRr

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F ^ : i A L S


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?,
[ J Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Business
Address

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


Ix] Check here i f the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS,
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
I

Under Municipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more ofthe Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ J Yes

No

[ J No person direptly 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?

[ J Yes

[ J No

B. FURTHER CERTIFICATIONS ,
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: ;If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year comphance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
a.

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;

b.

have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment rendered against them in connection with:
obtaining, attempting to obtain, or performing a pubhc (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;

c.

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 clause B.2.b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found liable in a civil proceeding, or in any crimiiial or civil action, incliiding actions
conceming environmental violations, instituted by the City or by the federal governinent, any
state, or any other unit of local government.

3. The certifications in subparts 3, 4 and 5 concern:


the Disclosing Party;
any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in
connection with the Matter, including but not limited to all persons or legal entities disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as tlie ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
|
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Cbntractor 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 13

Neither the Disclosing Party, nor any Contractor, nor any Affihated Entity of either the Disclosing Party
or any Contractor nor any Agents haye, during the five years before the date this EDS is signed, or, with
respect to a Contractor, an Affihated Entity, or an Affiliated Entity of a Contractor during the five 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 pubhc 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;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offeijise of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the
Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. 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:
MA

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general pubhc, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also Ust the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ J is

M is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City,"
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as' defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 ofthe Municipal Code: Does any official or employee
of the City have^ a financial interest in his or her own name or in the name of any other person or
entity in the Matter?
[ J Yes
^ 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, proceed to PartE.
2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a fmancial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[JYes

MNo

3. If you checked "Yes" to Item D.L, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X ^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 pohcies
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 F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING ,
!

. I

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

(If no explanation appears or begins on the Hnes above, or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A.L through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Applicant and all proposed
subcontractors to submit the following information with their bids or in writing at the outset of
negotiations.
Is the Disclosing Party the Applicant?
[ J Yes

[ J 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 regulations? (See 41 CFR Part 60-2.)
[ ] Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract CompHance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ J Yes
[ J No .
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[JYes
[JNo
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION V l l ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any
contract or other agreement between the Apphcant 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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
decUning to allow the Disclosing Party to participate in other transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the public on its Internet site' and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public 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 release's any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l.
The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2
If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List.System ("EPLS") maintained by the U. S. General Services Administration.
F.3
If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent ofthe
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.
NOTE: I f the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City.
American Real Estate Investments No. 2, LLC

(Print or type name of Disclosing Parly)


F i r s t American Bank, i t s Manager
(Sign here)
Frederick M. Snow
(Print or type name of person signing)
Executive Vice President and General Counsel
(Print or type title of person signing)

Signed and sworn to before me on (date) ^^^l^^^li^^f^^<!^ - ^ A x ^ ^ - ^

Notary Public.
Commission expires:
Page 12 of 13
DM2\6056331.1

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Paitner thereof currently has a "familial relationship" with
any elected city official or department head. A "famihal relationship" exists if, as of the date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.
"Applicable Party" means (1) all executive officers ofthe Disclosing Party hsted in Section H.B.l.a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosing Party is a general
partaership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a hmited
partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a
limited habihty company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. ;"Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently
have a "familial relationship" with an elected city official or department head?

[ J Yes

M No

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 faniilial relationship.

Page 1'3 of 13

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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal
Code?
!
t

[ ij Yes

<

[XJiNo

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 Section
2-92-416 ofthe Municipal Code?
[JYes

[JNo

[X] Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKJ^OWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATIOISf MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

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;
First American Bank
Check ONE of the following three boxes:
Indicate whether tho Disclosing Party submitting this EDS is:
1. [ ] the
OR
American Real Estate Investments No. 2, LLC.
2. [x] a legal entity holding a direct or indirect lateiest in the /
State the legal name ofthe
Applicant ui which the Disclosing Party holds an interest; First American Bank, not personally, buTas
Qg_
Tmstee U/T/A dated April 6,2009 and Icnown as Trast No. 1-09-111
3. [ ] alegalentity with a right of control (see Section II.B.1.) State the legal name of the entity in
which the Disclosing Party holds aright of control:
B, B usiness address ofthe Disclosing Party;

C. Telephone; (847) 586-2583


D. Name of contact person:

iRsn i r>iiit Avpri'iB, Omvp Village, ininriis ^p,

Pax; -(847) 586-2583

Email; .droubitchek(5),firstambank.com

Donald Roubitchek

E. Federal Employer Identification No. (if you have one):


F, Brief description, of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if apphcable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 Soutii Wabash.
G. Which City agency or department is requesting this EDS? Department of Planning and Development
/
If the Matter is a contract being handled by the City's Depaitment of Piooiurement Services, please
complete the following;
Specification #

Ver. 01-01-12
DM2\6056406,1

and Contract#

Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING, PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person
[ ] Limited liabihty company
[ ] Publicly registered business corporation
[ ] Limited liability partnership
EK] 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:
hnois

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

[]No

M'N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


I . List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, Hst below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, Hmited Habihty company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE: Each lejgal entity listed below,must submit an EDS on its own behalf.
Name

'

Title

.qflfi attached Appendix C for li.st nf directors anri exPiniitivR nffirF-rR

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trast,


estate or other similar entity. If none, state "None." NOTE; Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any apphcant which is reasonably intended to achieve full disclosure.
Name

Business Address

Firat American Rank Onrpnratinn

Percentage Interest in the


Disclosing Party

1RRn I niil.q Avft.. F]\c P,rn\iP. Village, II Rnnn?

SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

KI No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship (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, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or adihinistrative
action on behalf of any person or entity other than; (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whetlier


retained or anticipated
to be retained)

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

BusinessAddress

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


]X\ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
'

<

Under Muniqipal Code Section 2-92-415, substantial owners of business entities that contract with
the City must remain in compHance with their child support obligations throughout the contract's term.
Has any person,who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obHgations by any Illinois court of competent jurisdiction?

[JYes

^ No

[ ] No person directly or indirectly owns 10% or more of the


Disclosing Party.

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

[ ] No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article r')(which the Apphcant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Apphcant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I appHes to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
a.

are not presently debarred, suspended, proposed for debarment, declared ineHgible or voluntarily
excluded from any transactions by any federal, state or local unit of government;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment rendered against them in connection with:
obtaining, attempting to obtain, or performing a pubhc (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;
c.

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 clause B.2.b. of this Section V;

d.

have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and

e.

have not, within a five-year period preceding 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.

3. The certifications in subparts 3, 4 and 5 concern:

'

the Disclosing Party;


any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in
connection with the Matter, including but not limited to all persons or legal entities disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affiliated Entity means a person or entity that directly or
indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affihated Entity or any
other official, agent or employee of the Disclosing Party, any Coiitractor 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 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affihated Entity, or an Affiliated Entity of a Contractor during the five years
before the date pf 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 pubHc officer or empl|0yee of the City, the State of IlHnois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for stich conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party niust explain below:
N/A

Page 6 of 13

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.
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none").
N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete Hst of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything
made generally available to City employees or to the general pubHc, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift Hsted below, please also list the name ofthe City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)
is

[ ] is not

a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal
Code. We further pledge that none of our affiliates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiHate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary):
N/A

Page7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-.156-110 of the Municipal Code: 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
MNo
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, proceed to Part E.
2. Unless spld pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes

[X] No

3. I f you checked "Yes" to Item D.l., provide the names and business addresses ofthe City
officials or employees having such interest and identify the namre of such interest:
Name

Business Address

Nature of 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. I f the Disclosing Party checks 2., the Disclosing Party must
disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
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 F E D E R A L L Y FUNDED MATTERS


NOTE: If the Matter is federally funded, complete this Section VI. I f the Matter is not federally
funded, proceed to Section VII. For purposes of this Section V I , tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING ,
I

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

(If no explanation appears or begins on the lines above, or if the letters "NA" or i f the word "None"
appear, it will be conclusively presumed that the Disclosing Party means that NO persons or enfities
registered under the Lobbying Disclosure Act of 1995 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
apphcable federal law, a member of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. 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 (H) 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".
5. If the Disclosing Party is the Applicant, the Disclosing .Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make .such certifications promptly available to the City upon request,

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Apphcant 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

I f "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmafive acfion programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
. [ ] Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
[ ] No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[]Yes
[]No
If you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION V I I - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE

'

The Disclosing Party understands and agrees that:


A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 parficipation in the Matter and/or
decHning to allow the Disclosing Party to participate in other transacfions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. 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 on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must stipplement 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 Arficle I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.
The Disclosing Party represents and warrants that;
Page 11 of 13
n -.. \. \M*f.>'i~w' <

F.l. The Disclosing Party is not definquent in the payment of any tax administered by the IHinois
Department of Revenue, nor are the Disclosing Party or its Affihated Enfities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not
use, nor permit their subcontractors to use, any facihty hsted by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F,3
If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any
contractors/subcontractors hired or to be hired in connection with the Matter certificafions equal in
form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certificafions or that the
Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.
NOTE: If the Disclosing Party cannot cerfify as to any of the items in F, 1., F.2. or F.3. above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that aH
certificafions and statements contained in this EDS and Appendix A (if applicable) are trae, accurate
and complete as of the date furnished to the City.
First American Bank
(Print or type name of Disclosing Party)

(Sign here)
Frederick M. Snow
(Print or type name of person signing)
Executive Vice President and General Counsel
(Print or type fitle of person signing)

Signed and sworn to before me on (date)


at C f i x ^
County, IHinois

(state)
Notary PubHc.

Commission expires:
Page 12 of 13
DM2\6056406.1

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Secfion 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 "famiHal relationship" with
any elected city official or department head. A "famihal relationship" exists if, as ofthe date this EDS is
signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner therepf is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic
partaer 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, motlier-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 Hsted in Section II.B.l.a., if the
Disclosing Party is a corporation; all partoers of the Disclosing Party, if the Disclosing Party is a general
partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited
partaership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a
limited Habihty company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently
have a "familial relationship" with an elected city official or department head?
[ ] Yes

[ ] No

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

Page 13 of 13

CITY OF CinCAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTLFICATION
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 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
!
[|]Yes
I
[X]:No
I

2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuantto Section
2-92-416 ofthe Municipal Code?
[ ]Yes

[ ]No

[X] Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

City of Chicago
Economic Disclosure Statement and Affidavit
Appendix C
First American Bank

Directors:
Martin J. Carmody
Michael F. Kashtan
William H. Kerdyk
James M. Lynch
Frederick M. Snow
John B. Ward
Thomas E. Wells, IV

Executive Officers:

Tifie:

Martin J. Carmody
Gene M. Coots
Brian T. Hagan
Robert L. Horsman
Kim M. Kohon
Noel R. Levasseur
James M. Lynch
Eduardo Monteagudo
Jane Nagel
John L. Olsen
Linda Overbey
Donald Roubitchek
Frederick M. Snow
Adelbert Spaan
John B.Ward
James Wargas
Thomas E. Wells, IV
Lawrence Zydowsky

Senior Executive Vice President


Executive Vice President
Executive Vice President
Executive Vice President
Executive Vice Prissident
Execufive Vice President
Vice Chairman
Executive Vice President
Executive Vice President
Executive Vice President
Executive Vice President
Executive Vice Prpsident
Executive Vice President & General Counsel
Executive Vice President
President
Executive Vice President
,
Chairman, Chief Executive Officer
Executive Vice President

DM2\6085508.I

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT
SECTION I " GENERAL INFORMATION
A, Legal n^me of the Disclosing Paity suhmitting this EDS, Include d/b/a/ if appUoablQi
First American Bank Corpoiation
Check OW ol the foUowthg three boxes;
Ittdicatc whether the DlBoloaJng Party submitthg thl.s EDS is;
1. [ ] the
OR
,
, First American Bank
2. 1x1 a Icgftl entity holding a direct 01 indirect itttorest in the/
State the legal name of the
Applioant m wiioh the Disclosing Paity holds m interest: First American Bank, not pBrsonally, bufss
Q

TtmtcB U/T/A dated Ajrii 6,2009 nnd Jmomi as Tmt No, 1-09-111

3. [ ] e legal entity with a right of control (see Scotiou n.B,L) State the legal name ofthe entity in
which tho Disclosing party holds a tight of, control;,
,
B, Bugimes.s address of the Disolqsing Parly;

C, Telephone; ;(647) 586-2585


D. Nanio of contact persQii;

.IRRO I puia AMj^PUft, FIV OrnvR vinapB,

Fax; -(847^ 686-2583 ..


Donald Roubitchek

illlnniB RQ

Emaih droubitchek@fIrstambank.com
^

B. Federal Employer Identification No. (if you have one);

. ^

F, Brief desoription of oontraot, transaction or other undertaking (referred to below as the'"Mattex") to


v/hich this EDS pertains. (InoMa projeot numhci and looatioii of property, if applicable);
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1016 South Wabash.
G, Which City agency or department ia requesting thia BDS? Department of Planning and Developmsnt
If the Matter is a oontraot being handled by the City's Depaitment of Procurement ServleeB, please
complete the following;
Speeifleation #

Vcr. 01-01-12
DM2\6Q97936.1

and Coatiaot #

Pago 1 of 13

SECTION I I - DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY

[]
[]
^
[]
[]
[]
[]

1. Indicate the nature of the Disclosing Party:


Person
[ ] Limited hability company
Publicly registered business corporation
[ ] Limited liability partnership
Privately held business corporation
[ ] Joint venture
Sole proprietorship
[ ] Not-for-profit corporation
General partaership
(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:
Delavvare
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

KNo

. [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full nam^s and titles of all executive officers and all directors ofthe entity.
NOTE; For not-for-profit corporations, also list below all members, if any, which are legal entities, I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s)'.
If the entity is a general partnership, hmited partnership, limited hability company, limited liabihty
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management oftiheDisclosing Party.
NOTE: Each legal entity listed below must submit an EDS on its own behalf.
Name

Title
Saa attahhRd Appfinrilx O for li.qt nf filrftntnr.s and HXRoiirivn nffinRr.q..

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples
of such an interest include shares in a coiporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a tmst,


estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Fir.qf AmRrican Rank nnrpnratinn

IR.i^n I niil.<; Aw

Percentage interest in the


Disclosing Party
FJk Rrtwa V/illag<> II Rnnn?

^.65%

Einployee Stock Ownership Plan


; Carolyn C. Wells Trust under agreement dated 4/7/88 1650 Louis Ave., Elk Grove Village, IL 60007

12.39%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[]Yes

MNo

I f yes, please identify below the name(s) of such City elected official(s) and describe such .
relationship(s);
i

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES


The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained
or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total
amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose
employees who are paid solely through the Disclosing Party's regular payroll.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid hasis, or (2)
himself. "Lobhyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
If the Disclosing Party is uncertaia 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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party Fees (indicate whether


(subcontractor, attomey,
paid or estimated.) NOTE:
lobbyist, etc.)
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


^ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code 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.
1

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

M 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 comphance with that agreement?
[ ] Yes

[ ] No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Apphcant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; arid (ii) the
Applicant understands and acknowledges that compliance with Article I is a continuing requirement for
doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
a.

are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily
excluded from any transactions by any federal, state or local unit of govemmenti

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment rendered against them in connection with:
obtaining, attempting to obtain, or performing a pubhc (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;
c.

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 clause B.2.b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more pubhc
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding 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
conceming environmental violations, instituted by the City or by the federal government, any
state, or any other unit of local government.

3. The certifications in subparts 3, 4 and 5 concem:


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

Pages of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affihated Entity, or an Affihated Entity of a Contractor duriag the five 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 pubhc officer or employee of the City, the State of Illinois, or any agency of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospeqtive bidders, in restraint of freedom competition by agreement to bid a fixed price or
otherwise; or
'
c. made an admission of such cpnduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or
d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials,
agents or partners, is barred from contracting with any unit of state or local government as a result of
engaging in or being convicted of (1} bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigguig or bid-rotating.
5. . Neither' the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party,must explain below:
N/A

Page 6 of 13

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,
8. 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 12month period preceding the execution date of this EDS, an employee, or elected or appointed official,
of the City of Chicago (if none, indicate with "N/A" or "none"),
N/A

9, 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 tbis EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift hsted below, please also list the name ofthe City recipient,
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1, The Disclosing Party certifies that the Disclosmg Party (check one)
l;] is

is not

a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.


2,

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affihates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 pf the Municipal Code. We understand that becoming a predatory
lender or becoming an affihate of a predatory lender may result in the loss ofthe privilege of doing
business with the City,"
If the Pisclosing Party is unable to make this pledge because it or any of its affihates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 of the Municipal Code, explain here (attach additional pages if necessary);
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements,
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1, In accordance with Section 2-156-110 ofthe Municipal Code: 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
M 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,, proceed to Part E,
2, Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively,
"City Property Sale"), Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes

[X] No

3, If you checked "Yes" to Item D.l,, provide the names and business addresses of the City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of 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 paragraph 2. Failure to
. I

Pages of 13

comply with these disclosure requirements may make any contract entered into with the City ia
connection with the Matter voidable by the City.
X 1. The Disclosing Party verifies that the Disclosing Parly 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 Disclpsing 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
pohcies. The Disclosing Party verifies that the followmg 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; I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally
funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City
and proceeds of debt obligations of the City are not federal funding.
A. CERTIFICATION REGARDING LOBBYING .
1. List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 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 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 hsted 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
apphcable federal law, a member of Congress, an officer or employee of Congress, or an employee 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy ofthe statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either; (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities",
5. If the Discloshig Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l , through A.4, above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B, CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is federally funded, federal regulations require the Apphcant 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;


1. Have you developed and do you have on file affirmative action programs pursuant to apphcable
federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal
Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
'
[ ] No
3. ' Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ ] Yes
[ ] No
If you checked "No" to question 1. or 2, above, please provide an explanation;

Page 10 of 13

SECTION V I I - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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 imderstands that
it must comply with all statutes, ordinances, and regulations on which this EDS is based.
B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties arid obligations on persons or entities seeking City contracts,
work, business, or transactions. The full text of these ordinances and a training program is available on
line at www.citvofchieaRo.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660, The Disclosing Party must comply fully
with the applicable ordinances.
C. I f 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 transactions with the City. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the pubhc on its Internet site ahd/or upon
request. Some oi aU of the infonnation provided on this EDS and ahy attachments to this EDS may be
made available to the pubhc on the Intemet, 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 infoimation submitted
in this EDS,
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing tarty must
update this EDS as the contract requires, NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code,
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l, The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department'of Revenue, nor are the Disclosing Party or its Affihated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not limited to, aU water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U. S. General Services Administration.
F.3 If the Disclosing Party is the Apphcant, the Disclosing Party 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 F.l, and F.2, above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide tmthfhl certifications,
NOTE: If the Disclosing Party cannot certify as to any ofthe items in F,l., F.2. or F,3, above, an
explanatory statement must be attached to this EDS.
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contaiped in this EDS and Appendix A (if applicable) are tme, accurate
and complete as ofthe date furnished to the City,
First American Bank Corporation
,,,
(Print or type name of Disclosing Party)
By;
(Sign here)
Frederick M. Snow
(Print or type name of person signing)
Executive Vice President and General Counsel
(Print or type titie of person signmg)

Signed and sworn to before me on (date)


at O i S t ^
^ County, nifaoia
y^^^^^^^y?
Commission expires: ( ^ C ' ' ^ ' ' ^ f

(state),
Notary Public.
\

OFFICIAL SEAL

JAMES M BERTON

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICLAJLS 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 percent. It Is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with
any elected city official or department head, A "famihal relationship" exists if, as ofthe date this EDS is
signed, the Disclosmg Party or any "Apphcable Party" or any Spouse or Domestic Partaer thereof is related to
the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or . domestic
partaer or as any of the foUowing, 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) ah executive officers o^'the Disclosing Party hsted in Section I[.B.l.a., if the
Disclosing Party is a corporation; all paxtaers ofthe Disclosing Party, if the Disclosing Party is a general
partaership; all general partners and Iknited "partners of the Disclosing Party, if the Disclosing Party is a limited
partaership; aU 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 percent ownership interest in the Disclosing Party, "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority;
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently
have a "famiUal relationship" with an elected city official or department head?
[ ] Yes

M No

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

Page 13 of 13

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIXB
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 percent (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 Municipal Cpde Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
[ ]Yes

[X]No

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 Section
2-92-416 ofthe Municipal Code?
[ ]Yes

[ ]No

[X] Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OP, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

City of Chicago
Economic Disclosure Statement and Affidavit
Appendix C
First American Bank Corporation

Directors:
William Y. Bogle
Martin J. Carmody
Caren M. Furbeyre
Michael F. Kashtan
William H. Kerdyk
.lames M, Lynch
Richard R, Matthias
Adelbert P,C. Spaan
John B. Ward
Thomas E. Wells, IV

Executive Officers:

Titie:

Martin J. Carmody
James M, Lynch
Donald Roubitchek
Frederick M. Snow
John B. Ward
Thomas E. Wells, IV

Senior Executive Vice President


President
Executive Vice President
Executive Vice President & General Counsel
Vice Chairman
Chairman, Chief Executive Officer

DM2\60!)7907,1

CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
ANJ) AFFIDAVIT
SECTION I - GENERAL INFORMATION
A, Legal name of tho Disclosing Party submitting this EDS. Include d/b/a/ if applicable;
First American Bank Corporation Employee Stock Ownership Plan
Check ONE ofthe followiiig three boxes;
Indicate whether the Disclosing Party submittmg this EDS is;
1. [ ] the
OR

Coiporation
2. ^ 8 l^gal entity holding a direct or indirect interest in the .First American Bank/ State the legal namo of the
Apphpant in which the Disclosing Party holds an interest; First Anrierlcan Bank, not personally, but as
Qg^
Tnistee U/T/A dated Apiil 6,2009 and kEOwn aa Trast No, i-09rl 11
3. [ ] a legal entity with aright of control (see Section n,B,l.) State the legal name of the entity in
which the Diselosing Party holds a right of control;
B, Business address of the Disclosmg Party:

^mn L nnis AvBnua, Rk nrfivg viiiflgp., iiiinnia finiifl

C. Telephono; (847) 586-8075 \ Pax: ,(847) 586-8075


D. Name of contact poison;

Jane Nagel

Email: ipagel@firstambaiik.com

E. Federal Employer Identification No, (if you have- one); ^


F, Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to
which this EDS pertains. (Include project number and location of property, if applicable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash,

G. Which City agency or department is requesting this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

and Contract if

Vcr, 01-01-12
DM2\6087748,1

Page 1 of 13
:

SECTION I I -r DISCLOSURE OF OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY

]
]
]
]
]
]
]

1. Indicate the nature of the Disclosing Party:


Person
[ ] Limited liability company
Publicly registered business corporation
[ ] Limited liability partnership
Privately held business corporation
[ ] Joint venture
Sole proprietorship
[ ] Not-for-profit corporation
General partnership
(Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership
[ ] Yes
[ ] No
Trust
Other (please specify)
Employee Stock Ownership Plan

2. For legal entities, the state (or foreign country) of incorporation or organization, i f applicable:
Illinois
3. For legal entities not organized in the State of Illinois: Has the organization registered to do
business in the State of Illinois as a foreign entity?
[ ] Yes

[ ] No

N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1. List below the full names and titles of all executive officers and all directors ofthe entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited hability company, limited liability
partnership or joint venture, list below the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party.
NOTE: Each legal enfity listed below, must submit an EDS on its own behalf.
Name

Title
See attached Appendix C for list of mfimhsrs of Admlnistrativfi CnrnmittfiR..

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None," NOTE; Pursuant to Section 2-154-030 of the
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name

Business Address

Percentage Interest in the


Disclosing Party

InhnWard

IfiSO 1 mils A V R , Flk GrnvP. VillaqB, 11 Rni1R

James Lynch

1650 Louis Ave., Elk Grove Village, IL 60118

1.4.07%

12.46%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(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, 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.
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets i f necessary)


Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V - CERTIFICATIONS
A. COURT-ORDERED CHILD SUPPORT COMPLIANCE
Under Municipal Code Section 2-92-415, substantial owners of business entities that contiact with
the City must rqmain in compliance with their child support obligations throughout the contract's term.
Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obligations by any Illinois court of competent jurisdiction?
[ ] Yes

M 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 comphance with that agreement?
[ ] Yes

[ ] No

B. FURTHER CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows: (i) neither the Apphcant nor any controlling person is currenfiy indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compHance with Article I is a continuing requirement for
doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
a.

are not presently debarred, suspended, proposed for debarment, declared ineHgible or voluntarily
excluded from any transactions by any federal, state or local unit of government;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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;
c.

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 clause B.2,b. of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding the date of this EDS, been convicted, adjudged
guilty, or found Hable in a civil proceeding, or in any criminal or civil action, including actions
concerning environmental violations, instituted by the City or by the federal govemment, any
state, or any other unit of local govemment,

3. The certifications in subparts 3, 4 and 5 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 "Affihated Entity" (meaning a person or entity that, directly or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation:
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or sta!te or local government, including
the City, using substantially the same management, ownership, or principals as the ineHgible 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 of the Disclosing Party, any Contractor or any Affihated Entity,
acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any
Contractor or any Affihated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five 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 of the federal
government or of any state or local government in the United States of America, in that officer's
or employee's official capacity;

b.

agreed or colluded with other bidders or prospective bidders, or been a party to any such
agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or
prospective bidders, in restraint of freedom of competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a, or b. above that is a matter of record, but
have not been prosecuted forjsuch conduct; or

d.

violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).

4, Neither the Disclosing Party, 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-rotatmg in
violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of
America that contains the same elements as the offense of bid-rigging or bid-rotating.
5, Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists
maintained by the Office of Foreign. Assets Control ofthe U.S. Department ofthe Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Endty List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Govemmental Ethics) ofthe
Municipal Code.
7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general pubHc, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift Hsted below, please also Hst the name ofthe City recipient.
N/A

C, CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1,

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is

'

[x] is not

a "financial institution" as defined in Section 2-32-455(b) ofthe Municipal Code.


2.

I f the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affiliates is, and none of them wiU become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING.INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same
meanings when used in this Part D. .
1. In accordance with Section 2-156-110 of the Municipal Code: 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
M No
NOTE: If youichecked "Yes" to Item D.L, proceed to Items D.2, and D.3. If you checked "No" to
Item D . l . , proceed to Part E.
2. Unless sbld 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?
[JYes

[x]No

3. If you checked "Yes" to Item D.l., provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter wiU
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 paragraph 2. Failure to
.

Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X
I . 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 prpfits from slavery or slaveholder insurance
policies. The Disclosiag Party verifies that the following constimtes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS


NOTE: I f the Matter is federally funded, complete this Section VI. I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , 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 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 i f 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 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 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.
Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. 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".
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


Ii

If the Matter is federally funded, federal regulations require the Apphcant 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:


1. Have you developed and do you have on file affirmative action programs pursuant to apphcable
federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal
Contract Comphance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
[ ] No :
3. Have you participated in any previous contracts or subcontiacts subject to the
equal opportunity clause?
. [ ] Yes
[ ] No
If you checked "No" to question 1. or,2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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.
B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The fuU text of these ordinances and a tiaining program is available on
line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N .
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the apphcable ordinances.
C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate,
any contiact or other agreement in cormection 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
decHning to allow the Disclosing Party to participate in other transactions with the City, Remedies at
law for a false statement of material fact may include incarceration knd an award to the City of treble
damages,
: j
D. It is the City's policy to make this document available to the public on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the pubHc on the Internet, in response to a Freedom of Information Actrequest, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified
offenses), the information provided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F. 1. The Disclosing Party is not dehnquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affihated Entities delinquent in paying any
fine, fee, tax or other charge owed to the City. This includes, but is not hmited to, aU water charges,
sewer charges, hcense fees, parking tickets, property taxes or sales taxes,
F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not
use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded
Parties List System ("EPLS") maintained by the U, S, General Services Administration.
F,3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F,l, and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to believe has not provided or cannot provide tmthful certifications.
NOTE; If the Disclosing Party cannot certify as to any ofthe items in F.l,, F.2. or F.3. above, an
explanatory statement must be attached to this EDS,
CERTIFICATION
Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City,
First American Bank Corporation Employee Stock Ownership Plaii

(Print or type name of Disclosing Paityj

(Print or type name of persbn signing)

(Print or type title of person signing)


Signed_and sworn to before me on (date
at C ^ f (
County, ni'no's

(state).
. Notary Pubhc,

Commission expires:
Page 12 of 13

OFFiCIAL SEAL
JAMES M BERTON
NOTARY PUBLIC - STATE OF ILLINOIS
MY COMMISSION EXPIRES 10./09/16

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 AppUcant, and (b) any legal entity which has a direct
ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with
any elected city official or department head, A "familial relationship" exists if, as ofthe 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
partaer 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, ^on-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 H.B.l.a., if the
Disclosing Party is a corporation; aU partners of the Disclosing Party, if the Disclosing Party is a general
partaership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited
partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a
limited hability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party, "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer, treasurer or secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Paitner thereof currently
have a "familial relationship" with an elected city official or department head?
[ ] Yes

|X] No

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

Page 13 of 13

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 Apphcant exceeding 7.5 percent (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 Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a
building code scofflaw or:problem landlord pursuant to Section 2-92-416 of the Municipal
Code?
i :
[ i ] Yes

iI

[X] No

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 Section
2-92-416 ofthe Municipal Code?
[ ]Yes

[. ]No

[X] Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


A N D AGREEMENT 'THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

City of Chicago
'
Economic Disclosure Statement and Affidavit
Appendix C
First American Bank Corporation Employee Stock Ownership Plan
Administrative Committee Members:

Titie:

Susan BerchioUi
Jane Nagel
Linda Overbey
Lauren Baldwin
Daniel O'Connor

Senior Vice President


Executive Vice President
Executive Vice President
Vice President
Vice President

DM2\6Q89023.1

CITYOFCHICAGO
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;
Carolyn C. Wells Trust under agreement dated 4/7/88
Check ONE ofthe foUowing three boxes;
Indicate whether the Disclosing Party submitting this EDS is;
1, [ ] file
OR
Corporation
2, Ix] a legal entity holding a direct or indirect interest in the First American Bank./State the legal name of the
Applicant in which the Disclosmg Party holds an interest; First American Bank, not personally, but a's
Q
Trustee U/T/A dated April. 6,2009 and known as Trast No, 1-09-111
3, [ ] alegalentity with a right of control (see Section n.B.l.) State the legal name of the entity in
which the Disclosing Party holds a right of control:
B, Business address ofthe Disclosmg Party;

C, . Telephone:

(847) 586-2586

D, Name of contact person:

Fax:

iR.gn i p.ii.^ Aw^nim. p\]< nmvp viliF.gf>, iiiinnk finun

(847) 586-2586

Email: twellsiv@firstambank.com

Thomas E. Wells IV

E, Federal Employer Identification No. (if you have one);


F. Brief description of contract, traasaction or other undertaking (referred to below as the "Mattei") to
which this EDS pertains. (Include project number and location of property, if apphcable):
Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requestmg this EDS? Department of Planning and Development
If the Matter is a contract being handled by the City's Department of Procurement Services, please
complete the following:
Specification #

Ver, 01-01-12

DM2\6087749.1

and Contract #

Page 1 of 13

SECTION II - DISCLOSURE OE OWNERSHIP INTERESTS


A. NATURE OF THE DISCLOSING PARTY
1. Indicate the nature of the Disclosing Party:
[ ] Person
[ ] Limited liabihty company
[ ] Publicly registered business corporation
[ ] Limited liabihty 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
EK] Trust
,
[ ] pther (please specify)

2.

For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Illinois

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

[jNo

[j^N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:


1, List below the full names and titles of all executive officers and all directors of the entity.
NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f
there are no such members, write "no members." For trusts, estates or other similar entities, list below
the legal titleholder(s).
If the entity is a general partnership, limited partnership, limited liability company, limited liability
partnership or joint venture, list belovv the name and title of each general partner, managing member,
manager or any other person or entity that controls the day-to-day management of the Disclosing Party.
NOTE: Each legal entity Hsted below must submit an EDS on its own behalf.
Name
Thomas F. WfilLs IV

Titie
Trustee

2. Please provide the following information concerning each person or entity having a direct or
indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples
of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.
Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust,


estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe
Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information
from any applicant which is reasonably intended to achieve full disclosure.
Name
Carnlyn C. Wfills

Business Address

Percentage Interest in the


Disclosing Party

Ifi.Sni mils AVR, Flk Grnvfi VillaQR, H

finfin?

100%

SECTION I I I - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal
Code, with any City elected official in the 12 months before the date this EDS is signed?
[ ] Yes

M No

If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
;

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES


The Disclosing Party must disclose the name and business address of each subcontractor, attomey,
lobbyist, accountant, consultant and any other person or entity whom the Disclosiag 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,
"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative
action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2)
himself, "Lobbyist" also means any person or entity any part of whose duties as an employee of
another includes undertaking to influence any legislative or administrative action.
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 13

Name (indicate whether


retained or anticipated
to be retained)

Business
Address

Relationship to Disclosing Party


(subcontractor, attorney,
lobbyist, etc.)

Fees (indicate whether


paid or estimated.) NOTE:
"hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)


\X\ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.
SECTION V -- CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE


Under Municipal Code 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 personjWho directly or indireptly owns 10% or more of the Disclosing Party been declared in
arrearage on any child support obHgations by any Illinois court of competent jurisdiction?
[ ] Yes

M 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 compHance with that agreement?
[ ] Yes

[ ] No

B. FURTHER 'CERTIFICATIONS
1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should
consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party
submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party
certifies as follows; (i) neither the AppHcant nor any controlling person is currently indicted or charged
with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any
criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the
Applicant understands and acknowledges that compHance with Article I is a continuing requirement for
doing business with the City. NOTE: If Article I appHes to the Applicant, the permanent compHance
timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section II.B.l. of this EDS:
i
i
a.

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;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal
offense, adjudged guilty, or had a civiljudgment 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 stamtes; fraud;
embezzlement; theft; forgery; bribery; falsification or destruction of records; making false
statements; or receiving stolen property;
c.

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 clause B.2.b, of this Section V;

d. have not, within a five-year period preceding the date of this EDS, had one or more public
transactions (federal, state or local) terminated for cause or default; and
e.

have not, within a five-year period preceding 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.

3. The certifications in subparts 3, 4 and 5 concem:


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 persbns or legal entities disclosed under
Section IV, "Disclosure of Subcontractors and Other Retained Parties");
any "Affiliated Entity" (meaning a person or entity that, directiy or indirectly: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity. Indicia of control include, without limitation;
interlocking management or ownership; identity of interests among family members, shared facilities
and equipment; common use of employees; or organization of a business entity following the
ineligibility of a business entity to do business with federal or state or local government, including
the City, using substantially the same management, ownership, or principals as the ineligible entity);
with respect to Contractors, the term Affihated Entity means a person or entity that directly or
indirectly controls the Contractor, is conttoUed by it, or, with the Contractor, is under common
control of another person or entity;
any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any
Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

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 five years before the date this EDS is signed, or, with
respect to a Contractor, an Affiliated, Entity, or an Affiliated Entity of a Contractor during the five 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 pubhc officer or employee of the City, the State of Illinois, or any agency ofthe federal
government or of any state or Ipcal government in the United States of America, intiiatofficer's
or employee's official capacity;

b.

agreed or colluded with other hidders 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 o^ competition by agreement to bid a fixed price or
otherwise; or

c.

made an admission of such conduct described in a. or b. above that is a matter of record, but
have not been prosecuted for such conduct; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance).
4. Neither the Disclosing Party, 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.
5. Neither the Disclosing Party nor any Affihated Entity is listed on any ofthe following lists
maintained by the Office of Foreign Assets Control of the U.S. Department ofthe Treasury or the
Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially
Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the
Debarred List.
6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters
2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) ofthe
Municipal Code.
7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further
Certifications), the Disclosing Party must explain below:
N/A

Page 6 of 13

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

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a
complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the
12-month period preceding the execution date of this EDS, to an employee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
made generally available to City employees or to the general public, or (ii) food or drink provided in the
course of official City business and having a retail value of less than $20 per recipient (if none, indicate
with "N/A" or "none"). As to any gift listed below, please also Hst the name of the City recipient.
N/A

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION


1.

The Disclosing Party certifies that the Disclosing Party (check one)

[ ] is

^ is not

a "financial institution" as defined in Section 2-32-455(b) of the Municipal Code.


2.

If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal
Code. We further pledge that none of our affihates is, and none of them will become, a predatory
lender as defined in Chapter 2-32 of the Municipal Code, We understand that becoming a predatory
lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing
business with the City."
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter
2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):
N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be
conclusively presumed that the Disclosing Party certified to the above statements.
D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS
Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same
meanings when used in this Part D.
1. In accordance with Section 2-156-110 of the jvlunicipal Code: 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
^ ] 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., proceed to Part E,
2. Unless sbld pursuant to a process of competitive bidding, or otherwise permitted, no City
elected official or employee shall have a financial interest in his or her own name or in the name of
any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold
for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively,
"City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power
does not constitute a financial interest within the meaning of this Part D.
Does the Matter involve a City Property Sale?
[ ] Yes

[x] No :

3. If you checked "Yes" to Item D.l., provide the names and business addresses ofthe City
officials or employees having such interest and identify the nature of such interest:
Name

Business Address

Nature of Interest

4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will
be acquired by any City official or eniployee.
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 paragraph 2. Failure to
Page 8 of 13

comply with these disclosure requirements may make any contract entered into with the City in
connection with the Matter voidable by the City.
X 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 F E D E R A L L Y FUNDED MATTERS


NOTE; I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally
funded, proceed to Section V I I . For purposes of this Section V I , tax credits allocated by the City
and proceeds of debt obligations of the City are not federal fundings
I
A. CERTIFICATION REGARDING LOBBYING
1. List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with
respect to the Matter; (Add sheets i f necessary);

(If no explanation appears or begins on the lines above, or i f the letters "NA" or i f 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 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 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.
Page 9 of 13

3. The Disclosing Party wiH submit an updated certification at the end of each calendar quarter in
which there occurs any event that materially affects the accuracy of the statements and information set
forth in paragraphs A . l . and A.2. above.
4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Intemal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities".
,
5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in
form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any
subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the
duration of the Matter and must make, such certifications promptly available to the City upon request.

B, CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY


If the Matter is jfederally 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 AppHcant?
[ ] Yes

[ ] No

I f "Yes," answer the three questions below:


1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes
[ ] No
2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal
Contract CompHance Programs, or the Equal Employment Opportunity Commission all reports due
under the applicable filing requirements?
[ ] Yes
[ ] No
3. Have you participated in any previous contracts or subcontracts subject to the
equal opportunity clause?
[ ] Yes
[ ] No
If you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION,


COMPLIANCE, PENALTIES, DISCLOSURE
The Disclosing Party understands and agrees that:
A. 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,
B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of
the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts,
work, business, or transactions. The fuH text of these ordinances and a tiaining program is available on
Hne at www,citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.
Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully
with the applicable ordinances.
C. 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 transactions with the City. Remedies at
law. for a false statement of material fact may include incarceration and an award to the City of treble
damages.
D. It is the City's policy to make this document available to the pubHc on its Internet site and/or upon
request. Some or all of the information provided on this EDS and any attachments to this EDS may be
made available to the public on the Internet, in response to a Freedom of Information Act request, or
otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible
rights or claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.
E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing
Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a
contract being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE; With respect to Matters subject to Article I of
'
Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified
offenses), the,information prpvided herein regarding eligibility must be kept current for a longer period,
as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.
The Disclosing Party represents and warrants that:
Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois
Department of Revenue, nor are the Disclosing Party or its Affihated Entities dehnquent in paying any
fine, fee, tax or other charge owed to the City, This includes, but is not limited to, ah water charges,
sewer charges, license fees, parking tickets, property taxes or sales taxes.
F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not
use, nor permit their subcontractors to use, any facility hsted by the U.S, E.P,A, on the federal Excluded
Parties List System ("EPLS") maintained by the U, S, General Services Administration.
F,3 If the Disclosing Party is the Applicant, the Disclosing Party 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 F.l. and F.2. above and will not, without the prior written consent of the
City, use any such contractor/subcontractor that does not provide such certifications or that the
Disclosing Party has reason to beheve has not provided or camiot provide tmthful certifications,
NOTE; If the Disclosing Party cannot certify as to any pf the items in F.l., F.2, or F,3, above, an
explanatory statement must be attached to this EDS,
CERTIFICATION
Under penaUy of perjury, the person signing below: (I) warrants that he/she is authorized to execute
this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate
and complete as ofthe date furnished to the City,
' C. Wells Trust under agi-eenient dated 4/7/88
3f DiscAosing Party)

ngn here)
Thomas E. Wells IV
(Print or type name of person signing)
Tmstee
(Print or type title of person signing)

Signed and sworn to before me on (date) ^^^^g^^feaigV^ ^ / y ^ / ^ .


at
County, Illinois
(state).
Notary Public.
OFFICIAL SEAL
JAMES M BERTON

Commission expires:.
Page 12 of 13

NOTARY PUBLIC STATE OF ILLINOIS


MY COMMISSION EXPIRES 105?/16

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 percent. It is not to be completed by any legal entity
which has only an indirect ownership interest in the Applicant.
Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with
any elected city official or department head. A "famihal 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
partaer or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle,
niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather
or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister,
"Applicable Party" means (1) all executive officers ofthe Disclosing Party Hsted in Section II.B,l.a., if the
Disclosing Party is a corporation; all partners ofthe Disclosing Party, if the Disclosmg Party is a general
partaership; all general partners and Hmited partners of the Disclosing Party, if the Disclosing Party is a limited
partaership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a
limited liabihty company; (2) all principal officers of the Disclosing Party; and (3) any person having more than
a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief
operating officer, executive director, chieffinancialofficer,tieasureror secretary of a legal entity or any person
exercising similar authority.
Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Paitner thereof currently
have a "familial relationship" with an elected city official or department head?
[ ] Yes

M No

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

Page 13 of 13

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 percent (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 Municipal Code Section 2-154-010, istaeApplicant or any Owner identified as a
building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal
Code?
[ I ] Yes

[X] No

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 Section
2-92-416 ofthe Municipal Code?
[ 3 Yes

[ ] No

[X] Not Applicable

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

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT


AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY
REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS,
AND THAT THE REPkESENTATIONS MADE IN THIS APPENDIX B ARE
SUBJECT TO THE C E : R T I F I C A T I 0 N MADE UNDER PENALTY OF
PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

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