02015-6394
Meeting Date:
9/24/2015
Sponsor(s):
Misc. Transmittal
Type:
Ordinance
Title:
Committee(s) Assignment:
ORDINANCE
BE IT ORDAINED BY THE CITY COUNCIL OF THE CITY OF CHICAGO:
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:
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,
SECTION 3:
This ordinance shall take effect upon its passage and due publication.
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
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 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
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
None (existing)
Maximum Building
Heigfit
993'
102' (existing)
LEED Certified +
Green Roof
None
FAR Area
Green Features
JAHN
SCALE: r=120'-0"
JAHN
COPYRIGHT O JAW. LLC 2015
ALL RIGHTS RESERVED
45
90
135
180
SCALE: 1"=18ff-0"
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SITE
SUB
SUHMART
K
GROSS AREA:
RIGHT-OF-WAY:
NET AREA:
41.884 SF
9,545 SF
32.339 SF
46.287 SF
SUB AREA B:
GROSS AREA:
RIGHT-OF-WAY:
NET AREA:
21,388 SF
7,440 SF
13,948 SF
15
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1006 S.
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900 S. MICHIGAN
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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.
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15
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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'
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Schuyler
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Crisham
ScHLi-iLER,
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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:
/ /
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
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.
CONFIRMATION OF AUTHORITY
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.
By:.
By:.
Robert Kantor, a Manager
By:
Robert Kantor, a Manager
CONFIRMATION OF AUTHORITY
TO WHOM IT MAY CONCERN:
PROPERTY OWNER:
By
Printed Name
Title
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.
INC.
'
NOT WaUDED
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CITY OF CHIGAGO
APPLICATION FOR AN AMENDMENT TO
THE CHICAGO ZONING ORDINANCE
1.
2.
3.
STATE NY
PHONE 212-206-6097
EMAIL 'singer@tiineequities.com
4.
CITY
ZIP CODE
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
FAX (312)565-8300
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.
10.
11.
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
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
. _ , 2015
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
APPLICANT:
ADDRESS:
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
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;
C. Telephone: (212)206-6097
Fa.x:
Email: rsinger@timeequitles.conri
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
[
[
[
[
[
[
[
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
Title
Manager
Member
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
Business Address
_50%
50%
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
Business
Address
Attorney
[K] NO-
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is
[K]
is not
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.
[]No
Page 10 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
(^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
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
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.
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:
Email: jordan@jkequities.com
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
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
Business Address
50%
[X] No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
[ J Yes
[X] No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is
[X] is not
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:
(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.
[X] No
Page 10 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)
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
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
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.
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:
Email: jordan@jkequities.com
Vcr. 01-01-12
and Contract #
Page 1 of 13
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
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
Business Address
75%
25%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such,
relationship(s):
Page 3 of 13
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
. [XJNo
Page 10 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
[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
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.
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:
Email: eli@oakcapitals.com
Ver. 01-01-12
and Contract #
Page 1 of 13
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
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
Business Address
50%
50%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
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
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
[ 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
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.
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:
Fax:
Email: rsinger@timeequities.com
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
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
^J N/A
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
Business Address
Francis Greenburger
19%
GT Holdings, LLC
76%
RK 2011 Trust
5%
M No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
M is not
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:
(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.
[JNo
Page 10 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
(JLLI^UM
/^As'
(Itate).
Notary Public.
Commission expires:
JOSEPHINE CINnUEMANl
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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:
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J No
Page 10 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
(Sign here)
Gounty, j n f ^ f j C \C _
M f llLMA
u
fi'f^
V^
4=
^
(itate).
-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
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
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.
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:
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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
M No
[ J N/A
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
Business Address
Isabelle Greenburger
Noah Greenburger
Claim Greenburger
Julia Greenburger
Morgan Greenburger
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J No
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
(Sign here)
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
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
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.
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:
C. Telephone: (212)206-6097
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Jane Kantor
David Becker
Bryan Becker
Elizabeth Katz
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
W is not
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.
[ J No
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)
'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
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
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.
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
Fax:
Email: isin^ger@tirneequities.c^^
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
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
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%
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
Business
Address
[KJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[KJ is
not
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.
[JNO
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
Robert Kantor
2v
JOSFPHIME CIMQUEMANI
Notary Public, Statf? ot New York
No, iPfjasai
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIXA
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
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.
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:
Email: jordan@jkequlties.com
Vcr. 01-01-12
and Contract #
Page 1 of 13
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?
[X] Yes
[J No
[] N/A
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
Business Address
50%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
[XJ No
Page 10 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
[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
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.
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:
Email: jordan@jkequitles.com
Ver. 01-01-12
and Contract #
Page 1 of 13
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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 organizafion registered to do
business in the State of Illinois as a foreign entity?
[JYes
[XJNo
[JN/A
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
Business Address
75%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
'
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
[XJNo
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
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
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.
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:
Email: jordan@jkequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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?
[ J Yes
[XJ No
[ J N/A
Title
J K Equities L L C
Manager/Class B Member
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
Business Address
10%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
[ J Yes
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
[XJ No
Page 10 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)
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
[ 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
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.
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:
Email: rosenbloom.brian@gmail.com
Ver. 01-01-12
and Contract #
Page 1 of 13
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
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
Business Address
49.5%
49.5%
1%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
[ J Yes
[XJ No
Page 10 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)
(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
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
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.
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:
Ver. 01-01-12
and Contract #
Page 1 of 13
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
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
Business Address
100%
[XJ No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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:
(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.
[XJNo
Page 10 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
(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
[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
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.
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:
Email: msiemer@bradleyassoc.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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?
[XJ Yes
[J No
[J N/A
Title
Manager
Manager
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
Business Address
MHSR L L C
SNJL L L C
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
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
Page 10 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)
AlliSONrMNO
NOTARY PUBUC - STATE OF ttXiNOIS
mi
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Email: msiemer@bradleyassoc.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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?
[XJ Yes
[J No
[J N/A
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
Business Address
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
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
Page 10 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)
< \ . i < i U j h
Commission expires:
Jslate>.
Notary Public.
1^
p
IO f iQ
i-ageizOT l i
AUJiSOWtKWG
'*T1T'TTrsag8Sflgfl3/i9
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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:
Email: sjarol@bradleyassoc.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
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)
(^'OlO
Notary Public.
NOTARY PUBUC-I
fOWBITIOtI
Commission expires:
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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
Chicago, IL 60601
Email: bjarol@bradleyassoc.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
N/A
[XJ No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
Page 10 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
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
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.
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:
Email: jake@bradleyassoc.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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?
[XJ Yes
[J No
[] N/A
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
Business Address
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
Business
Address
N/A
[XJNo
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
[XJ is not
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.
[XJ No
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:
j ^ ^
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B
BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION
This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity
which has a direct ownership interest in the Applicant exceeding 7.5 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
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.
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;
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
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 Ycs
[ J No
[xJ N/A
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
Business Address
RK2011 Trust
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
Business
Address
[ J No
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.
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.
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
The Disclosing Party cerfifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J Yes
[ J No
Page 10 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
(Sign here)
f i T
NotaryPublic^
No. 02VI6131C40
Commission expires; v
J ^ '^"'^1. ~^
.
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Fax:
Email; rsinger@timeequities.com
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.
Person
Publicly registered business corporafion
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
[ J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[JNo
Page 10 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)
/
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
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
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.
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:
C. Telephone; (212)206-6097
Fax;
Email: rslnger@tlmeequitles.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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
M No
[ J N/A
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
Business Address
Francis Greenburger
25%
GT Holdings, LLC
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
Business
Address
[ J Yes
^J No
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,
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J Yes
[ J No
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)
Commission expires; U l M ^
'2^0 I
'
Page 12 of 13
" IT
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Fax:
Email: rsinger@timeequitles.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
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
[ J No
[xJ N/A
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
Business Address
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
Business
Address
[ J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J No
Page 10 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
(Sign here)
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
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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:
Fax;
Email: rslnger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
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
M No
[ J N/A
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
Business Address
55 Fifth Avenue, 15th Floor
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J Yes
[ J No
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)
AAP^f><3^-^
(Print or type tifie of person signing)
'
Commission expires._
<^
Page 12 of 13
N0.02VI6131C40
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
M No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J No
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)
(slate).
NotaryPublic.
Commission expires: U ( ^ ^ 1 J ^ T - ^ 1 ^
Page 12 of 13
'
-
,
^
^
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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:
C. Telephone: (212)206-6097
Fax:
Email: rsinger@timeequities.com
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.
Person
Publicly registered business corporafion
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
Robert Kantor
Francis Greenburger
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[J'NO
Page 10 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)
'
^
Commission expires;
(Jtate).
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Fax:
Email; rsinger@timeequlties.com
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.
Person
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[JYes
[JNo
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
(Sign here)
expires;
(state).
Nou,ry Public,
"
(
Page 12 of 13
, . ^ & S T ^ ^ o . ^ ,
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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:
Fax:
Email: rsinger@timeequities.com
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.
Person
,
Publicly registered business corporation
Privately held business corporation
Sole proprietorship
General partnership
Limited partnership
Trust
2.
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
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
Business Address
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
Business
Address
^J No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
^J is not
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.
[ J No
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
(Sign here)
ckte) J^j^iiWrr^oif
UA\L(date).
Commission expires
l
/
>7
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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
Fax: (847)403-8109
Email: dgnffin@flr5tambank.com
_^
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
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
Title
Fypir.utlva Vine Prfislrient
Dawn Griffin
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
Business Address
mCiViJ
i n n % hPHpfirlal IntArpgt
M No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
M No
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
I
[ ] is
^] is not
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:
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.
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
Page 10 of 13
',
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)
Senior- Vice P r e s i d e n t
(Print or type title of person signing)
(state).
Notary Public.
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
^ ] 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
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.
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
Fax;
847-586-2583
Donald Roubitchek
Eftail; droubitchek@firstanibank.com
^_
Ver. 01-01-n
DM2\6066331.1
and Contract #
Page 1 of 13
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
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
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
Business Address
M No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
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
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ J is
M is not
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:
. 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.
[ J No
,'
1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
[ ] Yes
[ ] 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
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
Notary Public.
Commission expires:
Page 12 of 13
DM2\6056331.1
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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;
Email; .droubitchek(5),firstambank.com
Donald Roubitchek
Ver. 01-01-12
DM2\6056406,1
and Contract#
Page 1 of 13
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
'
Title
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
Business Address
KI No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship (s);
Page 3 of 13
BusinessAddress
<
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
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.
'
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
is
[ ] is not
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;
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,
[ ] No
Page 10 of 13
'
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)
(state)
Notary PubHc.
Commission expires:
Page 12 of 13
DM2\6056406.1
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.
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
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;
illlnniB RQ
Emaih droubitchek@fIrstambank.com
^
. ^
Vcr. 01-01-12
DM2\6Q97936.1
and Coatiaot #
Pago 1 of 13
[]
[]
^
[]
[]
[]
[]
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
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
Business Address
IR.i^n I niil.<; Aw
^.65%
12.39%
MNo
I f yes, please identify below the name(s) of such City elected official(s) and describe such .
relationship(s);
i
Page 3 of 13
Business
Address
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
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.
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.
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
is not
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:
(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.
[ ] No
Page 10 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)
(state),
Notary Public.
\
OFFICIAL SEAL
JAMES M BERTON
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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,
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
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:
Jane Nagel
Email: ipagel@firstambaiik.com
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
:
]
]
]
]
]
]
]
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
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
Business Address
InhnWard
James Lynch
1.4.07%
12.46%
M No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
Page 3 of 13
Business
Address
M No
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,
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is
'
[x] is not
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:
(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.
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
Page 10 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
(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
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
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.
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
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
Fax:
(847) 586-2586
Email: twellsiv@firstambank.com
Thomas E. Wells IV
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
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
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
Business Address
finfin?
100%
M No
If yes, please identify below the name(s) of such City elected official(s) and describe such
relationship(s):
;
Page 3 of 13
Business
Address
M No
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.
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.
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
The Disclosing Party certifies that the Disclosing Party (check one)
[ ] is
^ is not
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:
(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.
[ ] No
Page 10 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)
Commission expires:.
Page 12 of 13
CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A
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
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.