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Legislation Referred to Committees at the Chicago City Council Meeting10/16/2013

Section 3f - Aldermanic Introductions Containing Economic Disclosure Statements

Agreement(s) - Easement

TransportationPublic way easement agreement withPresence Saints Mary & Elizabeth MedicalCenter for pedestrian overpass

O2013-76051 RedactedRecord

Moreno (1)Waguespack (32)

Class 6(b) Tax Incentive(s)

EconomicSupport of Class 6(b) tax incentive for 4227North Knox LLC

R2013-8782 RedactedRecord

Arena (45)

Historical Landmark Fee Waiver(s)

ZoningLandmark fee waiver for property at 2774 NMilwaukee Ave

Or2013-6093 RedactedRecord

Colón (35)

ZoningLandmark fee waiver for property at 2760 NMilwaukee Ave

Or2013-6374 RedactedRecord

Colón (35)

Plat(s) of Subdivision

TransportationApproval of plat of Pullman Park Phase 2Subdivision

O2013-75985 RedactedRecord

Beale (9)

TitleFile # Committee ReferralSponsor(s)

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10/16/2013

Moreno (1) Waguespack (32) Ordinance

Public way easement agreement with Presence Saints Mary & Elizabeth Medical Center for pedestrian overpass Committee on Transportafion and Public Way

ORDINANCE FOR LONG TERM EASEMENT

WHEREAS, The City of Chicago ('City") is a home rule unit of government by virtue of the provisions of the Constitution of the State of Illinois of 1970 and, as such, may exercise any power and perform any function pertaining to its government and affairs; and

WHEREAS, the City wishes to support the charitable, educational and philanthropic activities of established Not for Profit Corporations and encourage the continued viability and growth of their activities; and

WHEREAS, in furtherance of such activities, many Not for Profit Corporafions must move large numbers of vulnerable clients between adjacent properties that are bisected by public streets and alleys that are still required for public use; and

y WHEREAS, the City wishes to facilitate Not for Profit-originated services to the public, and provide safe passage above public street(s) and alley(s) where necessary, for no compensation; and

WHEREAS, Presence Saints Marv & Elizabeth Medical Center, an Illinois Not for Profit corporation organized and existing under and by virtue of the Statues of the State of Illinois ("Grantee") is owner of the hospital properties commonly identified as 2200 -2224, 2234 - 2248, & 2201 - 2259 W. Division Street (together, the "Site"); and

WHEREAS, Grantee currently uses the Site for hospital purposes; and

WHEREAS, the City Council of the City of Chicago, after due investigation and consideration, has determined that the nature and extent ofthe public use and the public interest to be subserved is such as to warrant a long term easement for a pedestrian overpass over the public street; and

WHEREAS, Grantee has constructed a pedestrian overpass (the "Pedestrian Overpass') to bridge the public right of way between hospital buildings at the Site; and

WHEREAS, Grantee has expended substantial sums in constructing the Pedestrian Overpass and related construction in order to facilitate the interconnection between the hospital buildings at the Site; and

WHEREAS, the Pedestrian Overpass will continue to promote public health, safety and welfare by allowing patients, medical staff, program participants, staff and visitors to traverse between the Grantee's Site's hospital buildings, protected from weather and from vehicular traffic; and

WHEREAS, the Pedestrian Overpass requires the use of the public right-of-way, specifically the air rights above the grade of the street limited to the elevations as set forth in the Plat of Easement, attached hereto and made a part hereof as Exhibit A; and

WHEREAS, the Department of Transportation has determined that the Pedestrian Overpass will not interfere with the City's traffic infrastructure and will benefit the citizens ofthe City of Chicago; and

WHEREAS, the City is willing to grant Grantee an easement on the same terms and conditions set forth in the Public Way Easement Agreement (the "Public Way Easement Agreement") attached hereto and incorporated herein as Exhibit B; now, therefore,

Be it Ordained by the City Council of the City of Chicago;

SECTION 1. The foregoing recitals are hereby incorporated herein and adopted as the findings of the City Council.

SECTION 2. The Commissioner of the Department of Transportation (the "Commissioner") or a designee of the Commissioner is each hereby authorized, along with the approval of the City's Corporation Counsel as to form and legality, to execute and deliver the Public Way Easement Agreement, subject to the Plat of Easement attached hereto and made a part hereof as Exhibit A. between Grantee and the City, in the form attached hereto as Exhibit B and made a part hereof, and such other supporting documents as may be necessary or appropriate to carry out and comply with the provisions of the Public Way Easement Agreement.

SECTION 3. If any provision of this ordinance shall be held to be invalid or unenforceable for any reason, the invalidity or unenforceability of such provision shall not affect any of the other provisions of this ordinance.

SECTION 4. The Public Way Easement Agreement herein provided for is made upon the express condition that within one hundred eighty (180) days after the passage of this ordinance. Presence Saints Mary & Elizabeth Medical Center shall file or cause to be filed for recording in the Office of the Recorder of Deeds of Cook County, Illinois a copy of the Public Way Easement Agreement, together with its accompanying Plat of Easement as approved by the Department of Transportation's Superintendent of Maps and Plats, as well as a separately recorded oversized and legible copy of the same Plat of Easement for greater clarity.

SECTION 5. This ordinance shall take effect upon its passage and need not be recorded.

SECTION 6. The Public Way Easement Agreement will take effect upon recording.

Easement approved:

Jabe Kk Commissioner of Transportafion

Approved as to form and legality:

Richard Wendy Deputy.Corporation Gounsel

Honorable Proco Joe Moreno Alderman 1 st Ward

Honorable ScptfWagu^pack Alderman 32f Wafd

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EXHIBIT B TO ORDINANCE

This Instrument Prepared By and After Recording Return to: Karen Bielarz Senior Counsel City of Chicago Department of Law 121 North LaSalle Street Room 600 Chicago, Illinois 60602

(The Above Space For Recorder's Use Only)

Public Way Easement Agreement (Pedestrian Bridge)

This Agreement (the Agreement") is entered into as of this day of 2013, by and between the City of Chicago, an Illinois home rule municipal corporation, by and through its Department of Transportation, (the "City") and Presence Saints Mary and Elizabeth Medical Center, a not-for-profit corporation organized and existing under and by virtue of the statutes of the State of Illinois ("Grantee"). City and Grantee together shall be referred to herein from time to time as the "Parties".

Witnesseth:

WHEREAS, Grantee is the owner of real property commonly known as 2200-2224, 2234-2248, and 2201-2259 W. Division Street, Chicago, Illinois, as legally described on Exhibit A attached hereto and made a part hereof (the "Property"), and currently improved with buildings that serve as the Grantee's medical campus; and;

WHEREAS, Grantee, an Illinois not for profit institution, is the owner of the medical buildings along W. Division Street bounded by N. Oakley Boulevard and N. Leavitt Street; and

WHEREAS, the adjacent buildings together shall be referred to herein from time to time as the Overpass Buildings ("Overpass Buildings"); and

WHEREAS, Grantee erected and was previously permitted for a pedestrian overpass ("Overpass") to connect the Overpass Buildings over and above the grade of the City's public right-of-way ("Street") by approximately one thousand six hundred and forty one (1641) square feet, and twenty six thousand nine hundred and seventy eight (26,978) cubic feet, more or less ("Easement Area"), as more fully described on the Plat of Easement ("Plat") attached hereto as Exhibit B: and

WHEREAS, the Overpass will continue to require the use of the street, specifically use of certain of the air rights above the street, as more fully depicted on the Plat; and

WHEREAS, the Grantee requires the use of the Overpass, which lies above the grade of the street, and the Easement Area, for safe pedestrian movement within the Overpass Buildings; and

WHEREAS, the Overpass will benefit the facility by allowing vulnerable patients, visitors, doctors and other pedestrians to traverse between the Overpass Buildings protected from the weather and vehicular traffic; and

NOW, THEREFORE, in consideration of the above preambles, the mutual covenants herein contained, and other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties agree as follows:

1. Grant of Easement Area. The City hereby grants to Grantee an easement ("Easement") to use and occupy, in accordance with this Agreement, those certain limited air rights in and above the Street in the Easement Area, as identified and legally described on the Plat, for the installation, operation, maintenance, repair and replacement of the Overpass. The Parties hereto may, upon review and approval of the Commissioner ("Commissioner") of the Department of Transportation, or any successor department ("CDOT"), substitute a revised Easement legal description for the Easement legal description set forth on Exhibit C attached hereto and made a part hereof, subject to review and approval ofthe City's Corporation Counsel.

2. Terms. The following terms and conditions apply to the Easement:

(a) The Easement is an easement appurtenant in favor of Presence Saints Mary and Elizabeth Medical Center and its successors and assigns.

(b) The Easement is granted for a term of twenty (20) years ("Term") provided that the Grantee or any successor to Grantee as owner of the hospital is recognized by the Federal Government as a not-for-profit entity.

(c) The Easement shall burden the Easement Area as the servient tenement.

(d) Grantee warrants to the City that it is the owner ("Owner") of the adjacent Property, is owner of the Overpass structure, and that the Grantee has sufficient title and fee interest to/in the Property to enter into this Agreement.

(e) The public way Easement granted pursuant to this Agreement constitutes a contemporaneous grant of interest in real property and is not executory in nature.

(f) Grantee shall not transfer any interest in the Easement without prior written consent by the Commissioner, which shall not be unreasonably withheld (provided, however, that such consent shall not be required in connection with any transfer of ownership ofthe hospital to another not-for-profit corporation).

3. Grantee's Obligations.

(a) The Grantee expressly warrants that the Overpass is designed and constructed in compliance with all federal, state and local laws and regulations. The Grantee further expressly warrants that the Overpass is designed and constructed in compliance with accessibility standards, including, but not limited to: (1) the Americans with Disabilities Act of 1990, 42 U.S.C. 12101, et seq., and the regulations promulgated thereunder; (2) the Illinois Environmental Barriers Act (410 ILCS 25/1 et seq. (1996)); (3) The Illinois Accessibility Code, 71 III. A. Code 400; and (4) all local City ordinances, codes, regulations.

(b) The Grantee shall be responsible for obtaining ongoing approvals of and payment for any and all removals, relocations, alterations, additional maintenance and restorations of or to any utility or public service structures or facilities, or any structures or facilities located in or adjacent to the Easement Area which are owned by the City, including pavements, bridges, poles, and other facilities and utilities, which are or may be necessary or appropriate to facilitate work related to the Overpass. The Grantee shall be responsible for obtaining the consent of and making suitable arrangements with all entities owning and having an interest in such structures and facilities, including any City department.

(d) The Grantee shall secure all necessary permits, including but not limited to, building permits.

4. Uses Within the Easement Areas.

a) The Overpass shall be open for use by the public at such times that the Overpass Buildings are open to the public.

b) The Grantee may not authorize the use of the Overpass for any purpose that will substantially interfere with the use ofthe Overpass by the public.

c) The Grantee may utilize the Overpass for exhibits, displays and the like that shall not substantially interfere with the public's use described in this Agreement.

d) Grantee may establish reasonable rules and regulations related to the use by the public of the Overpass. Grantee may at its sole discretion control the use of and access to the Overpass Buildings through the Overpass. Notwithstanding the foregoing, the City reserves a right to access the Overpass and Easement Area for City business purposes and services available to all similarly situated improvements.

5. Overpass Alterations.

Grantee may from time to time replace, remodel or demolish all or any portion of the Overpass so long as the Grantee secures the prior written approval of the Commissioner (or any successor department's Commissioner) and City.Council for alterations that may affect the Easement Area or other portions ofthe public right-of-way before making any alterations to the Overpass that would change the description provided on the Plat.

6. Not for Profit. The Grantee covenants that it is a not-for-profit entity. In the event of a change in the Grantee's not-for-profit status, or Grantee's transfer of any interest

in the Easement, except as permitted by Section 2(f) hereof, the Easement will immediately terminate and the new owner of the Property must apply for an easement or promptly remove the Overpass at the new owner's sole cost and expense.

7. Removal and Restoration. Grantee shall have the right to terminate this Easement at any time. Upon termination of the Easement granted by this Agreement the Grantee, without cost or expense to the City, shall promptly remove the Overpass, and all other structures and facilities related to the Overpass as may be located in the Easement Area and other affected public way at the Grantee's sole cost and expense. Grantee shall restore the public way to the extent altered, disturbed, or damaged by the installation, construction, use, operation, inspection, maintenance, repair, replacement or removal of the Overpass, and all work related thereto, to a proper condition under the supervision and to the satisfaction of the Commissioner and in accordance with the Municipal Code of Chicago.

8. Indemnity. Except with respect to the negligent or wrongful intentional acts of City (to the extent the same are the cause of an injury or loss to a third person). Grantee hereby indemnifies and agrees to hold harmless and defend City from and against any and all claims, demands, damages, lawsuits, legal proceedings, losses, liens, liabilities, judgments, orders or decrees, and all reasonable costs and expenses (including, without limitation, reasonable attorneys' fees, court costs, and other reasonable expenses related to litigation), arising from or as a result of the death of, or any accident, injury, loss or damage whatsoever caused to the City, any natural person, or the City's property, including but not limited to the Easement Area and all other impacted City right-of-way, the property of any person, arising out of, or occurring in any manner relating to the Easement Area, or the Overpass. In the event any legal action is taken against City or its agents or any claim is made relating to the Easement Area or the Overpass, the City may elect to tender said defense to Grantee which shall and must defend such action or claim at Grantee's own expense and City shall cooperate with Grantee in the defense thereof. City shall have the right to join Grantee as a party defendant in any such legal action. This indemnity shall not be the exclusive remedy of the City, and City shall maintain whatever other right of indemnity it may have under common law, by statute, or by ordinance.

9. Grantee's Operation, Maintenance and Securitv ofthe Easement Area and Overpass during the Term ofthis Agreement.

(a) Grantee shall maintain the Easement Area and Overpass at its sole cost and expense.

(b) Grantee shall maintain the Easement Area and Overpass so that the improvement does not unduly interfere with any use of the public way by the City, the public, or any person or entity authorized to use or occupy the public way.

(c) Grantee shall conduct regular, documented inspections of the Overpass and the Easement Area and maintain the Overpass and Easement Area in a structurally sound, clean, aesthetically attractive, and usable condition consistent with the public use required by this Agreement. All Overpass and Easement Area maintenance records shall be made available to CDOT upon CDOT's written request for such documentation to Grantee.

(d) Grantee shall attach no fixtures, post no verbiage, signage, symbols, art or

advertising of any kind on the structure, or on the interior of the structure that may be visible from the exterior, other than the name of Grantee hospital in fixed letters no larger than one sixth of the functional height of the structure as permitted under a compensated Use of the Pubiic Way permit submitted to the Department of Business Affairs & Consumer Protection, or its successor department. The Grantee shall not lease nor enter into any agreement for the Overpass or Easement Area lying over, under, on or in the public way for advertising space purposes, or for any other promotional use(s) for the Grantee or any third parties.

(e) Grantee shall cooperate with the City concerning the coordination of uses of the public way, including prompt responses to inquiries, attending meetings and site visits, and providing complete disclosure of information concerning the Easement Area and Overpass.

(f) Grantee shall pay for any and all utility expenses incurred with respect to the operation, maintenance, repair, replacement, and/or removal, or any part thereof, of the Overpass, or any part thereof, within the Easement Area.

(g) Grantee shall provide security over the Easement Area and Overpass at its sole cost and expense.

10. Citv Has No Maintenance and Operational Duties. The Grantee acknowledges that City is not responsible for the operation, maintenance, repair, replacement, and/or removal, or any part thereof, of or security of the Easement Area and the Overpass, and City has no obligations with respect thereto (other than the provision, through the exercise of the City's right to access the Overpass and Easement Area for City business purposes and services available to all similarly situated improvements).

11. Insurance.

(a) The Grantee shall procure and maintain, at all times, or shall cause to be procured and maintained, all of the types and coverages of insurance specified below, with insurance companies authorized to do business in the State of Illinois, covering all operations under this Agreement, whether performed by the Grantee or any of its contractors.

(b) The kinds and amounts of insurance required are as follows:

(i) Workers' Compensation and Occupational Disease Insurance.

Workers' Compensation and Occupational Disease Insurance, in statutory amounts, covering all employees who are to provide Work under this Agreement. Employers' liability coverage with limits of not less than One Million Dollars ($1,000,000) each accident, illness or disease.

(ii) Commercial Liability Insurance (Primary and Umbrella).

Commercial General Liability Insurance, or equivalent, with limits of not less than Five Million Dollars ($5,000,000) per occurrence for bodily injury, personal injury, and property

damage liability. All premises and operations, products/completed operations, independent contractors, explosion, collapse, underground, pollution (if commercially available), separation of insureds, defense and contractual liability coverages are to be included. The City is to be named as an additional insured on a primary non-contributory basis for any liability related directly or indirectly to this Agreement.

Contractors performing work for Grantee must maintain limits of not less than $2,000,000 with the same terms herein.

(iii) Automobile Liability Insurance. (Primary and Umbrella)

When any motor vehicles (owned, non-owned and hired) are used in connection with work to be performed, the Grantee provide or cause to be provided. Automobile Liability Insurance with limits of not less than Two Million Dollars ($2,000,000) per occurrence for bodily injury and property damage. The City is to be named as an additional insured on a primary, non-contributory basis.

Contractor performing work for Grantee must maintain limits of not less than $1,000,000 with the same terms herein.

(c) Additional Requirements

The Grantee must provide and cause any of its contractors to provide the City of Chicago, Department of Transportation, 30 North LaSalle Street, Room 500, Chicago, Illinois 60602-2570, original Certificates of Insurance, to be in force on the date of this Agreement, and Renewal Certificates of Insurance, or such similar evidence, if the coverages have an expiration or renewal date occurring during the term of this Agreement. The receipt of any certificate does not constitute agreement by the City that the insurance requirements in the Agreement have been fully met or that the insurance policies indicated on the certificate are in compliance with all Agreement requirements. The failure of the City to obtain certificates or other insurance evidence from Grantee and contractor is not a waiver by the City of any requirements for the Grantee to obtain and maintain the specified coverages. The Grantee and contractor must advise all insurers of the Agreement provisions regarding insurance. Non-conforming insurance does not relieve Grantee and contractor of the obligation to provide insurance as specified herein. Non-fulfillment of the insurance conditions may constitute a violation of the Agreement, and the City retains the right to stop work until proper evidence of insurance is provided.

Grantee agrees to make commercially reasonable efforts to obtain from its insurers, when and if available in the industry, a certificate providing that such coverage shall not be suspended, voided, canceled, non-renewed, or reduced in scope or limits except after thirty (30) days' prior written notice by certified mail, return receipt requested, has been given to the City.

Any deductibles or self-insured retentions on referenced insurance coverages must be borne by Grantee and contractor.

The Grantee hereby agrees and will cause its contractors to agree that insurers waive their rights of subrogation against the City of Chicago, its employees, elected officials, agents, or representatives.

The coverages and limits furnished by Grantee and contractor in no way limit the Grantee's and contractor's liabilities and responsibilities specified within the Agreement or by law.

Any insurance or self-insurance programs maintained by the City of Chicago do not contribute with insurance provided by the Grantee and contractor under the Agreement.

The required insurance to be carried is not limited by any limitations expressed in the indemnification language in this Agreement or any limitation placed on the indemnity in this Agreement given as a matter of law.

If Grantee or contractor is a joint venture or limited liability company, the insurance policies must name the joint venture or limited liability company as a named insured.

The Grantee must require the contractor to provide the insurance required herein. All contractors are subject to the same insurance requirements of Grantee unless otherwise specified in this Agreement.

The City's Risk Management Department maintains the right to modify, delete, alter or change these requirements.

12. Default The Grantee shall be in default hereunder in the event of a material breach by Grantee of any term or condition of this Agreement including, but not limited to, a representation or warranty, where Grantee has failed to cure such breach within sixty (60) days after written notice of breach is given to Grantee by City setting forth the nature of such breach. Failure of City to give written notice of breach to Grantee shall not be deemed to be a waiver of the City's right to assert such breach at a later time. If the default is not capable of being cured within the sixty (60) day period, then provided Grantee has commenced to cure the default and is diligently proceeding to cure the default within the sixty (60) day period, and thereafter diligenfiy prosecutes such cure through to completion, then the sixty (60) day period shall be extended for the length of time that is reasonably necessary to cure the default. If the default is not cured in the time period provided for herein, the City may institute such proceedings at law or in equity as may be necessary or desirable to cure and remedy the default, including but not limited to, terminafion of this Agreement and removal of the Overpass at the Grantee's sole expense.

13. Compliance With Law. The Grantee agrees that the Easement Area and Overpass shall be used, and any alterations to the Overpass shall be constructed, installed, used, operated, inspected, maintained, repaired and replaced in complete compliance with all applicable laws, statutes and ordinances.

14. Partial Invalidity. If any clause, sentence or other portion of this Agreement shall become illegal, null or void for any reason, or shall be held by any court of competent jurisdiction to be so, the remaining portion hereof shall remain in full force and effect.

15. Notices. Any and all notices or other communications required or permitted pursuant hereto shall be in writing and shall be deemed to have been given if and when personally delivered or on the next following business day if transmitted by reputable overnight carrier. Notices shall be addressed to Grantee and City at their respective

addresses set forth below, or to such substitute address as Grantee or City may have designated by notice in accordance herewith:

If to City:

Commissioner of Transportation 30 North LaSalle Street, Room 500 Chicago, Illinois 60602 Attn: Maps and Plats / Vacations

With a copy to:

Department of Law 121 North LaSalle Street, Room 600 Chicago, Illinois 60602 Attn: Senior Corporation Counsel

Real Estate and Land Use Division

If to Grantee:

Presence Saints Mary and Elizabeth Medical Center c/o Presence RHC Corporation 200 S. Wacker Drive Chicago, Illinois 60606 Attn: General Counsel

With a copy to:

Ms. Donna Pugh Foley & Lardner, LLP 321 N. Clark Street, Suite 2800 Chicago, IL 60654

16. Illinois Law. This Agreement has been negotiated, executed and delivered at Chicago, Illinois and shall be construed and enforced in accordance with the laws of Illinois, including the law of public trust with respect to the use and occupation of the public way.

17. Execution And Recordation of Agreement. The execution and recordation of this Agreement shall be subject to the finalization of all utility negofiations and further provided that the Grantee supplies the City with sufficient proof of ownership of the Property, and any other documents that the City may deem necessary.

18. No Third-Party Beneficiaries. This Agreement shall be binding upon and inure to the benefit solely of Grantee and City and their respective successors, assigns, licensees and legal representatives. This document and the terms hereof are intended solely for the benefit of the parties hereto and their successors, licensee and assigns, as

expressly referred to herein. No other person shall have any rights, responsibilities or obligations hereunder nor may such person enforce any of the terms or be entitled to any of the benefits hereof.

19. Authority and Validity. Each party represents and warrants to the other party that (i) this Agreement has been duly authorized, executed and delivered by it and (ii) this Agreement constitutes the legal, valid and binding obligation of it, enforceable against it in accordance with its terms.

20. Miscellaneous.

(a) The terms, benefits, and privileges set forth in this Agreement shall be deemed and taken to be covenants running with the Property and shall be binding upon the Grantee, its successors and assigns having any interest in the Property.

(b) If any provision of this Agreement, or any paragraph, sentence, clause, phrase, or word or the application thereof is held invalid, illegal, null or void for any reason, or shall be held by any court of competent jurisdiction to be so, the remainder of this Agreement shall be construed as if such invalid part were never included and this Agreement shall be and remain valid and enforceable to the fullest extent permitted by law provided that this Agreement, in its entirety as so reconstituted, does not represent a material change to the rights or obligations of either ofthe Parties.

(c) In the event the time for performance hereunder falls on a Saturday, Sunday, or legal holiday, the actual time for performance shall be the next business day.

(d) This Agreement and the accompanying Plat shall be governed by, and construed in accordance with, the internal laws of the State of Illinois. In the event that an adjudication of any kind shall be required in connection with this Agreement, the Parties agree that the venue therefor shall be the state or federal courts located in Cook County, Illinois, whichever may be applicable.

(e) This Agreement constitutes the entire contract between the Parties with respect to the subject matter of this Agreement, and may not be modified except by an instrument in writing signed by all the Parties and dated a date subsequent to the date of this Agreement.

(f) Each Party agrees that it will execute and deliver such other reasonable documents and take such other reasonable actions as may be reasonably requested by the other party to effectuate the purposes and intention of this Agreement.

21. Business Relationships.

The Grantee acknowledges (A) receipt of a copy of Section 2-156-030 (b) of the Municipal Code of Chicago, (B) that it has read such provision and understands that pursuant to such Section 2-156-030 (b) it is illegal for any elected official of the City, or any person acting at the direction of such official, to contact, either orally or in wrifing, any other City official or employee with respect to any matter involving any person with whom the elected City official or employee has a "Business Relationship" (as defined in Section 2-156-080 ofthe Municipal Code of Chicago), or to participate in any discussion in any City Council committee hearing or in any City Council meeting or to vote on any matter involving the person with whom an elected official has a Business Relationship, and (c) notwithstanding anything to the contrary contained in this

Agreement, that a violation of Section 2-156-030 (b) by an elected official, or any person acting at the direction of such official, with respect to any transaction contemplated by this Agreement shall be grounds for termination of this Agreement and the transactions contemplated hereby. The Grantee hereby represents and warrants that no violafion of Section 2-156-030 (b) has occurred with respect to this Agreement or the transactions contemplated hereby.

22. Patriot Act Certification.

The Grantee represents and warrants that neither the Grantee nor any Affiliate thereof (as defined in the next paragraph) is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury, the Bureau of Industry and Security of the U.S. Department of Commerce or their successors, or on any other list of persons or entities with which the City may not do business under any applicable law, rule, regulation, order or judgment: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

As used in the above paragraph, an "Affiliate" shall be deemed to be a person or entity related to the Grantee that, directly or indirectly, through one or more intermediaries, controls, is controlled by or is under common control with Grantee, and a person or entity shall be deemed to be controlled by another person or entity, if controlled in any manner whatsoever that results in control in fact by that other person or entity (or that other person or entity and any persons or entifies with whom that other person or entity is acting jointly or in concert), whether directly or indirectly and whether through share ownership, a trust, a contract or othenwise.

23. Prohibition on Certain Contributions Mayoral Executive Order 2011-4.

Grantee agrees that Grantee, any person or entity who directly or indirectly has an ownership or beneficial interest in Grantee of more than 7.5 percent ("Owners"), spouses and domestic partners of such Owners, Grantee's contractors (i.e., any person or entity in direct contractual privity with Grantee regarding the subject matter of this Agreement) ("Contractors"), any person or entity who direcfiy or indirectly has an ownership or beneficial interest in any Contractor of more than 7.5 percent ("Sub-owners") and spouses and domestic partners of such Sub-owners (Grantee and all the other preceding classes of persons and entities are together, the "Identified Parties"), shall not make a contributiori of any amount to the Mayor of the City of Chicago (the "Mayor") or to his political fundraising committee (i) after execution of this Agreement by Grantee, (ii) while this Agreement or any Other Contract is executory, (iii) during the term of this Agreement or any Other Contract between Grantee and the City, or (iv) during any period while an extension of this Agreement or any Other Contract is being sought or negotiated.

Grantee represents and warrants that from the later to occur of (a) May 16, 2011, and (b) the date the City approached the Grantee or the date the Grantee approached the City, as applicable, regarding the formulation of this Agreement, no Identified Parties have made a contribution of any amount to the Mayor or to his political fundraising committee.

Grantee agrees that it shall not: (a) coerce, compel or intimidate its employees to make a contribution of any amount to the Mayor or to the Mayor's political fundraising committee; (b) reimburse its employees for a contribution of any amount made to the Mayor or to the Mayor's political fundraising committee; or (c) Bundle or solicit others to bundle contributions to the Mayor or to his political fundraising committee.

Grantee agrees that the Identified Parties must not engage in any conduct whatsoever designed to intentionally violate this provision or Mayoral Executive Order No. 2011-4 or to entice, direct or solicit others to intentionally violate this provision or Mayoral Executive Order No. 2011-4.

Grantee agrees that a violation of, non-compliance with, misrepresentation with respect to, or breach of any covenant or warranty under this provision or violation of Mayoral Executive Order No. 2011-4 constitutes a breach and default under this Agreement, and under any Other Contract for which no opportunity to cure will be granted, unless the City, in its sole discretion, elects to grant such an opportunity to cure. Such breach and default entitles the City to all remedies (including without limitafion termination for default) under this Agreement, under any Other Contract, at law and in equity. This provision amends any Other Contract and supersedes any inconsistent provision contained therein.

If Grantee intentionally violates this provision or Mayoral Executive Order No. 2011-4 prior to the closing of this Agreement, the City may elect to decline to close the transaction contemplated by this Agreement.

For purposes ofthis provision:

"Bundle" means to collect contributions from more than one source, which is then delivered by one person to the Mayor or to his political fundraising committee.

"Other Contract" means any other agreement with the City of Chicago to which Grantee is a party that is (i) formed under the authority of chapter 2-92 of the Municipal Code of Chicago; (ii) entered into for the purchase or lease of real or personal property; or (iii) for materials, supplies, equipment or services which are approved or authorized by the City Council ofthe City of Chicago.

"Contribution" means a "political contribution" as defined in Chapter 2-156 of the Municipal Code of Chicago, as amended.

Individuals are "Domestic Partners" if they safisfy the following criteria:

(A) they are each other's sole domesfic partner, responsible for each other's common welfare; and

(B) neither party is married; and (C) the partners are not related by blood closer than would bar marriage in

the State of Illinois; and (D) each partner is at least 18 years of age, and the partners are the same sex, and

the partners reside at the same residence; and (E) two of the following four condifions exist for the partners:

1. The partners have been residing together for at least 12 months. 2. The partners have common or joint ownership of a residence. 3. The partners have at least two of the following arrangements:

a. joint ownership of a motor vehicle; b. a joint credit account; c. a joint checking account; d. a lease for a residence identifying both domestic partners as

tenants. 4. Each partner identifies the other partner as a primary beneficiary in a will.

"Political fundraising committee" means a "political fundraising committee" as defined in Chapter 2-156 of the Municipal Code of Chicago, as amended.

24. Failure To Maintain Eligibility To Do Business With The City.

Failure by Grantee or any controlling person (as defined in Section 1-23-010 of the Municipal Code of Chicago) thereof to maintain eligibility to do business with the City of Chicago as required by Secfion 1-23-030 of the Municipal Code of Chicago shall be grounds for termination of the Agreement and the transactions contemplated thereby. Grantee shall at all times comply with Section 2-154-020 ofthe Municipal Code of Chicago.

25. Inspector General and Legislative Inspector General.

It is the duty of every officer, employee, department, agency, contractor, subcontractor. Grantee and licensee of the City, and every applicant for certification of eligibility for a City contract or program, to cooperate with the City's Legislative Inspector General and with the City's Inspector General in any investigation or hearing undertaken pursuant to Chapters 2-55 and 2-56, respectively, of the Municipal Code of Chicago. The Grantee understands and will abide by all provisions of Chapters 2-55 and 2-56 of the Municipal Code of Chicago.

26. Waste Ordinance Provisions.

In accordance with Section 11-4-1600(e) of the Municipal Code of Chicago, Grantee warrants and represents that it, and to the best of its knowledge, its contractors and subcontractors, have not violated and are not in violafion of any provisions of Section 7-28 or Section 11-4 of the Municipal Code (the "Waste Sections"). During the period while this Amendment is executory. Grantee's, any general contractor's or any subcontractor's violation of the Waste Secfions, whether or not relating to the performance of tliis Agreement, constitutes a breach of and an event of default under this Agreement, for which the opportunity to cure, if curable, will be granted only at the sole designation of the Chief Procurement Officer. Such breach and default entitles the City to all remedies under the Amendment, at law or in equity. This section does not limit Grantee's, general contractor's and its subcontractor's duty to comply with all applicable federal, state, county and municipal laws, statutes, ordinances and executive orders, in effect now or later, and whether or not they appear in this Amendment. Non­compliance with these terms and condifions may be used by the City as grounds for the termination of this Amendment, and may further affect Grantee's eligibility for future contract awards.

27. Shakman Accord.

(a) The City is subject to the May 31, 2007 Order entitled "Agreed Settlement Order and Accord" (the "Shakman Accord") and the August 16, 2007 "City of Chicago Hiring Plan" (the "City Hiring Plan") entered in Shakman v. Democratic Organization of Cook County, Case No 69 C 2145 (United States District Court for the Northern District of Illinois). Among other things, the Shakman Accord and the City Hiring Plan prohibit the City from hiring persons as governmental employees in non-exempt positions on the basis of political reasons or factors.

(b) Grantee is aware that City policy prohibits City employees from directing any individual to apply for a position with Grantee, either as an employee or as a subcontractor, and from directing Grantee to hire an individual as an employee or as a subcontractor. Accordingly,

12

Grantee must follow its own hiring and contracting procedures, without being infiuenced by City employees. Any and all personnel provided by Grantee under this Agreement are employees or subcontractors of Grantee, not employees of the City of Chicago. This Agreement is not intended to and does not constitute, create, give rise to, or otherwise recognize an employer-employee relationship of any kind between the City and any personnel provided by Grantee.

(c) Grantee will not condition, base, or knowingly prejudice or affect any term or aspect to the employment of any personnel provided under this Agreement, or offer employment to any individual to provide services under this Agreement, based upon or because of any political reason or factor, including, without limitation, any individual's political affiliation, membership in a political organization or party, political support or activity, political financial contributions, promises of such political support, activity or financial contributions, or such individual's political sponsorship or recommendation. For purposes of this Agreement, a political organization or party is an identifiable group or entity that has as its primary purpose the support of or opposition to candidates for elected public office. Individual political activities are the activities of individual persons in support of or in opposition to political organizations or parties or candidates for elected public office.

(d) In the event of any communication to Grantee by a City employee or City official in violation of Section 27 (b) above, or advocating a violation of Section 27 (b) above. Grantee will, as soon as is reasonably practicable, report such communication to the Hiring Oversight Section of the City's Office of the Inspector General ("IGO Hiring Oversight"), and also to the head of the relevant City Department utilizing services provided under this Agreement. Grantee will also cooperate with any inquiries by IGO Hiring Oversight or the Shakman Monitor's Office related to the contract.

THE BALANCE OF THIS PAGE IS INTENTIONALLY LEFT BLANK

13

IN WITNESS WHEREOF, Grantee and City have caused this Agreement to be executed by their duly authorized officers, as of the day and year first written above.

PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER an Illinois not for profit corporation

By:

Name:

Tifie:

CITY OF CHICAGO, a municipal corporation, by and through its Department of Transportation

By:

Name: Gabe Klein Title: Commissioner

Approved As To Form And Legality (excluding the Legal Descriptions):

CITY OF CHICAGO Department of Law

B y : _

Name: Title:

14

EXHIBIT A LEGAL DESCRIPTION OF

PRESENCE SAINTS MARY & ELIZABETH MEDICAL CENTER

LAND ON NORTH SIDE OF WEST DIVISION STREET (NORTH OF SKYBRIDGE)-

PARCEL I:

LOTS 23 THROUGH 47 BOTH INCLUSIVE IN BLOCK 16 IN THE SUBDIVISION OF THE WEST 72 OF THE NORTHWEST OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN (ACKNOWLEDGED BY WATSON, TOWER AND DAVIS), RECORDED OCTOBER 10, 1856, ANTE-FIRE, AND RE-RECORDED JUNE 23, 1857, ANTE-FIRE, TOGETHER WITH ALL OF THE VACATED ALLEYS LYING WITHIN SAID BLOCK 16 AND, ALSO TOGETHER WITH THAT PART OF VACATED NORTH BELL AVENUE LYING BETWEEN SAID BLOCKS 15 AND 16 AND LYING SOUTH OF A LINE DRAWN BETWEEN THE NORTHEAST CORNER OF SAID BLOCK 15 AND THE NORTHWEST CORNER OF SAID BLOCK 16 AND LYING NORTH OF A LINE DRAWN BETWEEN THE SOUTHEAST CORNER OF SAID BLOCK 15 AND THE SOUTHWEST CORNER OF SAID BLOCK 16, ALL TAKEN AS ONE TRACT IN COOK COUNTY, ILLINOIS

EXCEPTING THEREFROM:

THAT PART OF BLOCKS 15 AND 16 IN THE SUBDIVISION OF THE WEST 'A OF THE NORTHWEST OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN (ACKNOWLEDGE BY WATSON, TOWER AND DAVIS), RECORDED OCTOBER 10, 1856, ANTE-FIRE, AND RE-RECORDED JUNE 23, 1857, ANTE-FIRE, TOGETHER WITH ALL OF THE VACATED ALLEYS LYING WITHIN SAID BLOCKS 15 AND 16 AND, ALSO TOGETHER WITH THAT PART OF VACATED NORTH BELL AVENUE LYING BETWEEN SAID BLOCKS 15 AND 16 AND LYING SOUTH OF A LINE DRAWN BETWEEN THE NORTHEAST CORNER OF SAID BLOCK 15 AND THE NORTHWEST CORNER OF SAID BLOCK 16 AND LYING NORTH OF A LINE DRAWN BETWEEN THE SOUTHEAST CORNER OF SAID BLOCK 16 AND LYING NORTH OF A LINE BETWEEN THE SOUTH EAST CORNER OF SAID BLOCK 15 AND THE SOUTHWEST CORNER OF SAID BLOCK 16, ALL TAKEN AS ONE TRACT, BOUNDED AND DESCRIBED AS FOLLOWS: BEGINNING AT A POINT IN THE SOUTH LINE OF SAID BLOCK 16 155.36 FEET WEST OF THE SOUTHEAST CORNER OF SAID BLOCK 16; THENCE NORTH 89 DEGREES 55 MINUTES 22 SECONDS WEST ALONG SAID SOUTH LINE A DISTANCE OF 175.69 FEET; THENCE NORTH 00 DEGREES 00 MINUTES 00 SECONDS EAST A DISTANCE OF 154.00 FEET; THENCE SOUTH 89 DEGREES 55 MINUTES 22 SECONDS EAST ALONG A LINE 154.00 FEET NORTH OF AND PARALLEL WITH SAID SOUTH LINE, A DISTANCE OF 175.69 FEET; THENCE SOUTH 00 DEGREES 00 MINUTES 00 SECONDS WEST 154.00 FEET TO THE POINT OF BEGINNING, IN COOK COUNTY, ILLINOIS

PARCEL II:

THAT PART OF BLOCKS 15 AND 16 IN THE SUBDIVISION OF THE WEST 'A OF THE NORTHWEST OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN (ACKNOWLEDGE BY WATSON, TOWER AND DAVIS), RECORDED OCTOBER 10, 1856, ANTE-FIRE, AND RE-RECORDED JUNE 23, 1857, ANTE-FIRE, TOGETHER WITH ALL OF THE VACATED ALLEYS LYING WITHIN SAID BLOCKS 15 AND

15

16 AND, ALSO TOGETHER WITH THAT PART OF VACATED NORTH BELL AVENUE LYING BETWEEN SAID BLOCKS 15 AND 16 AND LYING SOUTH OF A LINE DRAWN BETWEEN THE NORTHEAST CORNER OF SAID BLOCK 15 AND THE NORTHWEST CORNER OF SAID BLOCK 16 AND LYING NORTH OF A LINE DRAWN BETWEEN THE SOUTHEAST CORNER OF SAID BLOCK 16 AND LYING NORTH OF A LINE BETWEEN THE SOUTH EAST CORNER OF SAID BLOCK 15 AND THE SOUTHWEST CORNER OF SAID BLOCK 16, ALL TAKEN AS ONE TRACT, BOUNDED AND DESCRIBED AS FOLLOWS: BEGINNING AT A POINT IN THE SOUTH LINE OF SAID BLOCK 16 155.36 FEET WEST OF THE SOUTHEAST CORNER OF SAID BLOCK 16; THENCE NORTH 89 DEGREES 55 MINUTES 22 SECONDS WEST ALONG SAID SOUTH LINE A DISTANCE OF 175.69 FEET; THENCE NORTH 00 DEGREES 00 MINUTES 00 SECONDS EAST A DISTANCE OF 154.00 FEET; THENCE SOUTH 89 DEGREES 55 MINUTES 22 SECONDS EAST ALONG A LINE 154.00 FEET NORTH OF AND PARALLEL WITH SAID SOUTH LINE, A DISTANCE OF 175.69 FEET; THENCE SOUTH 00 DEGREES 00 MINUTES 00 SECONDS WEST 154.00 FEET TO THE POINT OF BEGINNING, IN COOK COUNTY, ILLINOIS

COMMONLY KNOWN AS 2233 WEST DIVISION STREET, CHICAGO, IL

PROPERTY INDEX NUMBERS: 17-06-125-001-0000 17-06-125-005-0000 17-06-125-043-0000 17-06-125-044-0000 17-06-125-045-0000

LAND ON SOUTH SIDE OF WEST DIVISION STREET (SOUTH OF SKYBRIDGE)-

PARCEL I:

THE SOUTH HALF (EXCEPT THE NORTH 33 FEET THEREOF TAKEN FOR WEST HADDON AVENUE) OF BLOCK 3 IN SUFREN'S SUBDIVISION OF THE SOUTHWEST QUARTER OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PARCEL II:

LOTS 1 AND 2, THE WEST HALF OF LOT 7, ALL OF LOTS 46 TO 50, INCLUSIVE, THE VACATED 16 FOOT ALLEY EAST OF AND ADJOINING SAID LOT 45 AND LOTS 46 TO 50, INCLUSIVE, IN THE SUBDIVISION OF THE NORTH PART OF BLOCK 3 IN SUFREN'S SUBDIVISION OF THE SOUTHWEST QUARTER OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PARCEL III:

LOTS 1, 2, 3 AND 4 IN THE RESUBDIVISION OF LOTS 3 TO 6, INCLUSIVE, AND THE EAST HALF OF LOT 7 IN THE SUBDIVISION OF THE NORTH PART OF BLOCK 3 IN SUFREN'S SUBDIVISION OF THE SOUTHWEST QUARTER OF SECTION 6, TOWNSHIP 39 NORTH, RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

16

PARCEL IV:

ALL OF THE PUBLIC ALLEYS AND ALL THAT PART OF HADDON AVENUE VACATED BY ORDINANCE PASSED BY THE CITY COUNCIL OF THE CITY OF CHICAGO ON NOVEMBER 21, 1971 AND RECORDED IN THE OFFICE OF RECORDER OF DEEDS OF COOK COUNTY, ILLINOIS ON JANUARY 4, 1972 AS DOCUMENT NO. 21766647.

PARCEL V:

EASEMENTS IN FAVOR OF PARCELS I THRU IV AS CREATED BY EASEMENT AND COVENANT AGREEMENT MADE BY ST. MARY'S AND ELIZABETH MEDICAL CENTER AND RESURRECTION SERVICES RECORDED MAY 27, 2010 AS DOCUMENT NO. 1014710022.

COMMONLY KNOWN AS 2233 WEST DIVISION STREET, CHICAGO, IL

PROPERTY INDEX NUMBERS: 17-06-301-024-0000

17

EXHIBIT B

PLAT OF EASEMENT (Attached)

18

EXHIBIT C LEGAL DESCRIPTION OF EASEMENT AREA

A 3 DIMENSIONAL EASEMENT 16.41 FEET IN WIDTH OVER THAT PART OF WEST DIVISION STREET RIGHT OF WAY (PER DOCUMENT RECORDED JULY 10, 1857 AS NO. 88896), LYING BELOW A HORIZONTAL PLANE AT THE VERTICAL ELEVATION (CHICAGO CITY DATUM) OF 51.73 FEET AND ABOVE THE HORIZONTAL PLANE CREATED BY CONNECTING THE VERTICES FORMED BY THE VERTICAL ELEVATION POINTS (SAID POINTS ALL HAVING A VERTICAL ELEVATION OF 35.29 FEET) ATTACHED TO THE FOLLOWING CALLS OF THE PERIMETER DESCRIBED AS FOLLOWS: COMMENCING AT THE INTERSECTION OF THE SOUTH LINE OF SAID WEST DIVISION STREET WITH THE WEST LINE OF NORTH LEAVITT STREET (PER DOCUMENT RECORDED JULY 10, 1857 AS NO. 88896); THENCE SOUTH 90°00'00" WEST (ON AN ASSUMED BEARING) ALONG THE SOUTH LINE OF SAID WEST DIVISION STREET, 277.24 FEET TO THE POINT OF BEGINNING; THENCE CONTINUING SOUTH 90°00'00" WEST ALONG THE LAST DESCRIBED COURSE 16.41 FEET; THENCE NORTH 00°05'11" WEST, 100.00 FEET TO A POINT ON THE NORTH LINE OF WEST DIVISION STREET RIGHT OF WAY AFORESAID; THENCE NORTH 90°00'00" EAST, ALONG SAID RIGHT OF WAY 16.41 FEET; THENCE SOUTH 00°05'11" EAST, 100.00 FEET TO THE POINT OF BEGINNING, IN THE CITY OF CHICAGO, COOK COUNTY, ILLINOIS.

CONTAINING: 1,641.00 SQ. FT., 26,978.04 CU. FT., MORE OR LESS

19

CITY OF CHICAGO ECONO.MIC DISCLOSURE STATE.VIE.NT

AND AFFIDAVIT

SECTION 1 - GENERAL INFORMATION

•A. I ,cg;il name of the Di.sclo.sing Party suhmittiny ihis F.D.S. Include d/b/a/ if applicable:

Presence S a i n t s Mary and E l i s a b e t h Medica l Center

Check OiNE of the following three boxes:

Indicate whether the Disclosing Party submitting this tOS is: 1. [X] tbe Applicant

OR 2. [ J a legal entity holding a direct or indirect interest m the .Applicant. State the legal name of the

Appiican; in which the Disclosing Party hold.s an interest: OR

3. [ J a legal entity with a right of control (see Section II.B. 1.) State the legal name ofthe entity in which the Disclosing Party holds a right of control:

B. Business address ofthe Disclosing Parly: 2233 W. D i v i s i o n S t r e e t

Chicago, I L 6062:

j u l i e . r o k n i c h ® C. TclcDhonc: *' ' ' '3)792-5269 pa_. . f. rriail: r e shea l t hca re . o r g

U. Name of conlact person; J u l i e Roknich

E. Federal Employer Identification No. ( if you have one)

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to vvhich this EDS pertains. (Include project number and location ofproperty, i f applicable):

S k y b r i d g e Easement f o r an e x i s t i n g 3:<ybridge on the 2200 b l o c k o f W. D i v i s i o n

G. Which City agency or department is requestmg this 1::DS'.' Chicago Dept . o f T r a n s p o r t a t i o n

I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the follov/ing:

Specification # and Contraci #

Vcr. 01-01-12 PajxC 1 of 13

SECTION 11 -- DISCLOSURE OF OWMERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

I . Indicate the nature ofthe Disclosiafi Party: Person [ ] Limited liability company Publicly registered business corporation [ j Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship f>'J Not-for-profit corporation General partnership (is the not-for-profit corporation also a 501(c)(3))? Limited partnership P<] Yes [ ] No Trust ( ] Other (please specify)

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

1 1 1 i n o i s

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

[JYes [ : No 1X]N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entiiy. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or olher similar entities, list below tbe legal titleholder(s).

I f the entity is a general partnership, limited partnership, limited liability comp^iny, 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 ;lic day-to-day management of the Disclosing Party, NOTE: Each legal entity listed below musl submit an EDS on its own behalf.

Name Title For l i s t of executive o f f i c e r s and directors See Exhibit A

Presence RHC CoroorstIon, .Sole Corporate Member

2. Please provide the following information concerning each person or entity having a direclor indirect beneficial inierest (including ownership) in excess of 7,5% of ihc Disclosing Pany. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, siate "None." .NOTE: Pursuant to Section 2-1 54-030 of the Municipal Code of Chicago ("Municipai Code'"), :he Ciry rnay require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business .Address Percentage Interest in the Disclosing Party

Presence RHC C o i p o r a t i o n i s che so l e c o r p o r a t e member.

SECTION I I I - BUSINESS RELATIONSHIPS W I T H CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business relaticiiship," as defined in Chapter 2-1 56 ofthe Municipal Code, with any City elected official in the 12 monilis before the date this EDS is signed?

[ ] Yes FJ ^'o

I f yes, please identify below the name(s) of such City elected ofricial(s) and describe sucb relation:ihip(s):

SECTION IV - DISCLOSURE OE SUKCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party bas retained or expects to retain in connection with the Matter, as well as the naturc ofthe relationship, and the total amount ofthe fees paid ur estimated to be paid. The Disclosing Party is nol required lo disclose employees who are paid solely through ths Disclosing Party's regular payroll.

"Lobbyist" means any person or entiiy who undertalces lo influence any legislative or administrative action on behalf of any person or entity cihcr 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 anolher includes undertaking :o intluence 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 as.k the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated .Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) lobbyisi, etc.) "hourly rate" or "t.b.d." is

not an acceptable response. Foley i I .ardncr LLF- 331 .V. ClarK S t . Chicago, I u A t i a r n e y 520,000 cntlmdced

G e n t i l e L A33ccidC«£ 550 Same CharLeo Place, Lonitarc, IL Survayor Leo3 than 520,t'03 eotimaced

(Add sheets i f necessary)

[ ] Check here i f lhe Disclosing Party has not retained, nor expects to retain, any sucb persons or entities.

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

L'nder M unicipai Code Section 2-92-4 1 5, substnniial owners of business entities that contract with the Cily must remain in compliance with their child support obligations throughoui the contract's term.

Has any person who directly or indirectly owns 1 0"o or mere of the Disclosing Party been declared in arrearage un any child support obligations by any Illinois court of competent jurisdiction?

[ ] Yes [ ] No pC] No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

I . Pursuani to Municipal Code Chapter 1-23, .Article 1 ("Article l")(which the Applicant should consul! for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is tbe Applicant and is doing business with the City, then the Disclo.sing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, nr has admilted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense invoiving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjur>-, dishonesty or deceit againsi an officer or employee of the City or any sister agency; and (ii) the Applicam understands and acknowledges that con;pliancc with Article 1 is a continuing requirement for doing business with the City. NOTE: If .Article I applies '.c the Applicant, the permanent compliance timefranio 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, 1. of this EDS;

a. are nol presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of govemment;

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 tu obtain, or performing a public (federal, state or local) transaciion or contract under a public transaction; a violation of federai or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statemenis; or receiving stolen property;

c. are nol presently indicted for, or criminally or civilly charged by, a govemmental eniity (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 fivc-ycar period preceding the date of this EDS, had one or more public transactions (federai, siaie or local) terminaied ior cause or default, and

e. have nol, 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 aciion, including actions concerning environmcmal violations, inslilutcd by the City or by the federal governmenl, any state, or any other unit of local government.

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosurc of Subcontractors and Olher Retained Panics"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Pany, is controlled by the Disclosing Party, or is, with the Disclosing Parly, under common control of another person or eniity. Indicia of control include, without limitation: interlocking management or ownership; idcniiiy of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entiiy to do business with federal or state or local govemment, 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 enlily ihal directty or indirectly conti-ols the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

• any responsible official of the Disclosing Party, any Contractor or any Affiliated Eniity or any other official, agent or employee uf the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuani lo 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 Coniractor, nor any Affiliated Entiiy of either the Disclosing Parly or any Coniracior nor any Agents have, during the five years before the date this EDS is signed, or, with respeci to a Contractor, an Affiliated Entiiy, or an Aftlliaicd Entity of a Contractor during the five years before the dale of such Contractor's or .'\ ffiliated Entity's contract or engagement in eonneclion with the Matter:

a. bribed or atiempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the Uniied Stales of America, in that officer's or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guiliy of agreement or collusion among bidders or prospective bidders, in rcstruini of freedom of toinpetition by agreemeni to bid a fined 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 nol been pro.secutcu toi such conduci; or

d. violated the provisions of Municipal Code Seciion 2-92-6 I 0 (Living VVage Ordinance).

4. .Neither the Disclosing Party, .Affiliated Entity cr Coniractor, 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) b:d-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 Ihe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Parly 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. Dcpiiituieiit of Commerce or their successors: ihc Specially Designated Nationals Lisl, the Denied Persons List, liic Unverified List, the Entity List and the Debarred Lisl.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-1 56 (Governmental Ethics) of the Municipal Code.

7. I f the Disclosing Party is unable lo certify to any of the above statements in ihis Part B (Further Certifications), lhe Disclosing Parry must e;\plain below:

Page 6 of 13

If the letters "N A," the word "None," ur no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified lo the above statements.

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

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Parly has given or caused lo be given, at any time during tbe 12-mon;h period preceding the execution date ofthis EDS, lo an employee, or elecied or appointed official, of the Ciiy of Chicago. For purposes uf this statement, a " g i f i " docs nol include: (i) anything made generally av.Tilablc to Cily employees or to the general public, or (ii) food or drink provided in the course nf officiai City business and having a retail value of less than S20 per recipient ( i f none, indicate wilh "N 'A" or "none"). As to any gift listed below, please also list the name of the City recipient. None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Parly certifies Ihat the Disclosing Party (check one)

( ] is P<] is not

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

2. I f the Disclosing Party IS a financial institution, then the Disclosing Parly pledges;

"We are not and will nol 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 alTiliate 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 necessaiy);

Page 7 of 13

I f the letters "N A," the word "None," or no response appears on the lines above, il 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 Municipa! Code have the same meanings when used in this Part D.

1. In accordance with Section 2-1 56-1 1 0 of the Municipal Code; Does any official or employee of the City have a financial interest in bis or her own name or in the name of .my other person or entity in the Matter'!''

[ ] Yes No

NOTE: I f you checked "Yes" to Item D. 1., proceed lo 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 pemiitted, nn City elected officiai 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 Properly Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial inierest within the meaning of this Part D.

Does the Mailer involve a City Property Sale?

( ] Yes f<] No

3. If you checked "Yes" to Item D, 1., provide the aames and business addresses of the City officials or employees having such inierest and identify the nature of such inierest:

Name Business Address Nature of Interest

4. The Disclosing Parly furiher certifies that no prohibited financial inierest 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 Parly must disclose below or in an attachment to ihis EDS all information required by paragraph 2. Failure to

Page S of 13

comply with these disclosure requirements may make any contraci entered inlo with the City in connection with the Matter voidable by the Cily

_ X _ 1 . The Disclosing Party verifies that the Disclosing Party bas searched any and all rccords of the Disclosing Party and any and all predecessor cniuics 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 rccords.

2. The Disclusing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Parly has found records of investmenls 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 ofany and all slaves or slaveholders described in those records:

SECTION V I - CER TIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE; I f the .Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed lo Seciion V I I . For purposes of this Section V I , tax credits allocated by the Cily and proceeds of debt obligations of the City arc nnt federal funding.

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosurc Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respeci to the Matter; (Add sheets if necessary).

(If no explanation appears or begins on the lines above, or if the letters "NA" or ifthe word "None" appear, it wil l be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure .•\ct :jf 1995 have made lobbying contacts on behalf of the Disclosing Parly 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 ofany agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member ofCongrcss, in connection with the award ofany federally funded contract, making any federally funded grant or loan, entering inlo any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contriici. gram, loan, or cooperative agreemeni.

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3. The Disclosing Party wili submit an updated cerlificalion at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and informaiion set forth in paragrapiis A 1 Diid A.2. abuve.

4. The Disclosing Parly certifies that cither: (i) ii is not an organization described in section 50 ! (c)(4) of '.he Internal Revenue Code of 1986; or (ii) it is an organization described in section 501 (c)(4) of lhe Iniernal Revenue Code of 1 9S6 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 . ihrougb A.4. above from all .subcontractors before i l awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the iVlatter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matter is federally iLiideJ, federal regulaiions require the Applicant and all proposed subcontractors lo suhmil ihc lollowing infonnation with ihcir bids or in writing at tbe outset of negotiaiions.

Is the Disclosing Party the Applicanl?

[ ] Yes ( ] No

I f "Yes," answer the ihrce (|iieslions below:

1. Have you developed and do you have on file atTirmative action programs pursuani lo applicable federal regulations? (Sec 4 1 CFR Pan 60-2.)

[ ] Yes 1 ] No

2. Have you filed with the Joint Rcfiorting Commitiee, the Director of the Office of Federal Contraci Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements''

( ] Yes [1 No

3. Have you participaled ir any previous coniracis or subcontracts subject to the equal opportunity clause?

( 1 Yes [ J Nn

I f you checked "No" lo question 1. or 2. above, please provide an explanation:

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SECTION v n - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, C O M P L I A N C E , PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees thai:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicanl and the City in connection with the Matter, whether procurement, City assistance, or other City aciion, and are material inducements to the City's e.xeculion of any contract or taking other action wilh respect lo the Matier. The Disclosing Party understands tbat it musl comply with all statutes, ordindnccs, 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 Cily contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cilvofchicaao.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .

Sedgwick St., Suite 500, Chicago, iL 60610, (312) 744-9650, The Disclosing Party musl comply fully with the applicable ordinances.

C. I f the City detemimes that any infonnation provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection v.'ith which it is submitted may be rescinded or be void or voidable, and Ihe City may pursue any remedies under the contract or agreement ( i f 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 Parly lo 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 Internel site ond/or upon request. Some or all of the in f ormation provided on Ibis EDS and any attachments to this EDS may be made available lo the public on the Internet, in response to a Freedom of Information Act requesl, or otherwise, By completing and signing this EDS, tbe Disclosing Party waives and releases any possible rights or claims which it may have againsi the City in connection with the public release of information contained in this EDS and also auihonzes the City to verify the accuracy of any information submitted in this EDS.

E. The infomiation provided in this EDS must be kept current. In the event of changes, the Disclosing Parly must supplement this EDS up to the time the City takes aciion on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires NOTE: With respect to Matters subject lo Article I of Chapier 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offei^scs), the infonmation 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 nol delinquent in the paymcni of any tax administered by the Illinois Departmeni of Revenue, nor are the Disclosing Parly or ils .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 It the Disclosing Puny is the .Applicant, the Disclosing Party and ils Affiliated Entilies wil l not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P..A. on the federal Excluded Parlies List System ("EPLS") maintained by the U. S. General Scn'iccs .Administration.

F.3 If the Disclosing Party is the .Applicant, ihe Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with ths Matter certifications equal in form and subsiance to tlicse in F. 1. 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 rot provided or cannoi provide truthful certifications.

.NOTE. If the Disclosing Party cannot certify as lo any of the items in F. 1., F.2. or F.3. above, an explunaiury siatemeni musl be attached lo this EDS.

C E R T I F I C A T I O N

Under penalty of perjury, the person signing below: (1) warrants ihat he/she is authorized lo 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.

t'res_ence Sa in t s Kary a.nd E l i z a b e t h t-'edi',:.al Center

(PH^it^i^ly^ie name ^Disclosini,

(Sign here)

M a r t i n Judci

(Print or lype name of person signing)

r_res vd-if n t /Chie f E:<ec'jt i/.;;e f_f i_ceL (Print or lype title of person signing)

Signed a^\swctn to before me on jdatc )

t HLyy'{y / iouni\

/ /

'OFRCIAL SEAL A Lisa Perez

X . ' jb-yiy)i :P-0/ = Commisi^on e)t;:ircs; 1 1 — I I—J

L Notary Pubtic, State of Illinois My Commission Expires 10/20/2013

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AWD AFFIDAVIT

APPENDLX A

F A M I L I A L RELATIONSHIPS WH H ELEC TED CTTY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Appticant, 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 entiiy which lias only sn indirect ownership interesi in ihc .Applicnnt.

Under Municipal Code Seciion 2-154-015, the Disclosing Party musl disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currenlly has a "familial relationship" with any elected city official or departmeni head, A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any aldennan, the city clerk, the city ireasurer or any city deparmieni head as spouse or domestic partner or as any nf the following, wlieihcr by blood or adoption; parent, child, brother or sisier, aunt or uncle, niece or nephew, grandparent, grandchild, falher-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or halfibrother or half-sister.

".Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section U.B. 1 .a., i f the Disclosing Pany is a corporation; all partners of the Disclosing Party, ifthe 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 mcmbcis ofthe Disclosing Pany, ifthe Disclosing Party is a limited liability company; (2) all priiitip:-il officers of tlie Disclosing Pany; 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 dircclor, chief financial of ficer, treasurer or secretary of a legal entity or any person exercising similar aulhority.

Docs the Disclosing Parly or any "Applicable Parly" or any Spouse or Domestic Partner thereof currently have a "familial rclaiionship" wiih an elecied city official or department head?

[ ] Yes [>n, No

Ifyes, please identify below (1) tlie name and title of such person, (2) the name ofthe legal entity lo which such person is connected; (3) llie name and litle of the elected city official or department head to whom such person has a familial relationship, and (4) the precise naturc of such famiiial relationship.

Paoe 13 of !3

EXIirBIT A TO CITY OF CHICAGO

ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT FOR

PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER

Officer/Director Name Title Role

Sandra Bruce President Officer

Tony Filer Tieasurer Ofticer

Jeannie C. Frey Secretary Officer

Martin Judd President/CEO, Board of Directors

Officer and Director

David DiLoreto, ,V1.D. Member, Board of Directors Director

Sister Mary Ellen Goeller, PHJC

Member, Board of Directors Director

Jean Blake Member, Board of Directors Director

Suni Desai, MD Member, Board of Directors Director

Richard Ferrans, M.D. Member, Fioard of Directors Director

Steven Yellen, M.D. Member, board of Directors Director

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal nsme cf the Disclosing Party subcnitting ibis EDS. Include d/b/a/ if appiicabic:

Presence RHC Corporat ion, an I l l i n o i s n o t - f o r - p r o f i t corporat ion

Check ONE ofthe following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] 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. PQ e 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: Pr«««pca s»int» M»ry «nij BHi«b«th n»cncai center

B. Business address of the Disclosing Party: 743S West Ta lco t t Avenue

Chicago, I L 60631

jul i e . r o k n i c h o

C. Telephone: (773) 792-5269 p^^; Email: reshealthcare. org

D. Name of contact person: J u l i e Roknich

E. Federal Employer Identification No. (if you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location ofproperty, if applicable):

Skybridge Easement f o r an e x i s t i n g skybridge on the 2200 block of w. D i v i s i o n

G. Which City agency or department is requesting this EDS? Chicago Dept. of Transportation

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vtr. 01-01-12 Page I of 13

SECTION I I - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

2. For legal entities, the state (or foreign country) of incorporation or organizadon, if applicable;

I l l i n o i s

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 pq N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which arc legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, 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 tbat controls the day-to-day management of che Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf

Name Title For l i s t of executive o f f i c e r s and directore See Exhibit A

Presence Healt:h Network i s sole corporate member.

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or otber similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Inierest in the Disclosing Party

Presence Health Network 100%

SECTION I I I - BUSINESS RELATIONSHIPS WITH CITV ELECTED OFFICIALS

Has tbe Disclosing Party bad 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?

[ 1 Yes pq No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey, lobbyist, accountant, consultant and any otber 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 tbe 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: (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 undertaldng to influence any legislative or administrative action.

Ifthe Disclosing Party is uncertain whether a disclosurc is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make Ihe disclosure.

Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party Fees (indicate whether (subcontractor, attomey, paid or estimated.) NOTE: lobbyist, etc.) "hourly rate' or "t.b.d." is

not an acceptable response.

(Add sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[JYes [ ] No No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ ] 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 wilh 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 1 applies to the Applicant, the pennanent compliance timeframe in Article I supersedes some fivc-ycar compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. Tbe 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 voluotarily excluded from any transactions by any federal, state or local unit of govemment;

b. have not, within a five-year period preceding the date of tbis EDS, been convicted of a criminal offense, adjudjied guilty, or had a civil judgment rendered against ihem 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 govemment, any state, or any other unil of local govemment.

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially tbe same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official ofthe Disclosing Party, any Contractor or any Affibatcd Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of tbe Uniied 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. Departmeni 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 tbe Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below:

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 12-month 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"). Hone

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete Ust 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 S20 per recipient (if none, indicate with "N/A" or "none"). As to any gifl listed below, please also list the name of the City recipieni. None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is pq is not

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

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

Page 7 of 13

Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that tbe 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 Sectioa 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 H N o

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 entiiy in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit ofthe City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning ofthis Part D.

Does the Matter involve a City Property Sale?

[ ] Yes N 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 tbe 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 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 contraci entered into with the City in connection wilh 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 entilies 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 rccords, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of tbe Disclosing Party wilh respect to tbe 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 tbe Disclosing Party means that NO persons or entilies registered under die Lobbying Disclosurc 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.

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 infonnation 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 seciion 501(c)(4) of the Intemal Revenue Code of 1986; or (ii) it is an organization described in seciion 501(c)(4) ofthe Intemal Revenue Code of 1986 bui has not engaged and will not engage in "Lobbying Activities".

5. Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A,4. above from all subcontractors before it awards any subcontraci and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ 1 Yes [ 1 No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant lo applicable federal regulations? (Sec 41 CFR Part 60-2.)

[ ] Yes [ ) No

2. Have you filed with the Joint Reporting Committee, tbe Direclor of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Vcs ( ) No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[]Yes I l N o

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

Page 10 of 13

SECTION V l l - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The cenifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agrcemcni between the Applicant and the Cily in connection with the Matter, whether procurement. City assistance, or other City action, and arc material inducements lo the Cily's execution ofany contract or taking other aciion with respeci to the Matter. The Disclosing Party understands that it musl comply wilh all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line al www.citvofchicaeo.ofe/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 contraci or agreement (if nol rescinded or void), at law, or in equity, including lerminating 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. I l is the City's policy to make this document available to the public on its Intemet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to (bis 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 againsi the City in connection wilh the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any informaiion submitted in this EDS.

E. The information provided in this EDS musl be kept curreni. In the event of changes, the Disclosing Party must supplement this EDS up to the time tbe Cily takes action on the Matter. I f the Matier 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: Wilh respect to Matters subject to Article I of Chapier 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Seciion 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 ofany 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 Cily. Tbis includes, but is nol 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 ase, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties Lisl System ("EPLS") maintained by the U. S. General Services Administration.

F.3 Ifthe Disclosing Party is the Applicant, the Disclosing Parly will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance lo 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 ihat the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f tbe 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 lo tbis EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute tbis 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.

Presence RHC Corporation

(Print or ty»c name of Disclosing Pa/ty)

By (Sign here)

Jeannie C. Frey

(Print or type name of person signing)

Corporate Secretary

(Print or type title of person signing)

G il' (Z^ Signed and swom to before me on (dale) at C P Q J C ^ County, ^"J. ( (stale)

Commission expires:.

1 OFnCMLWtt. ,e^^, Notary Public. i mmymA'tmcftmrn

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

F A M I L L \ L RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legai entity which has a direct ownership interest in tbe 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 dale 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 cily clerk, the city treasurer or any city department head as spouse or domestic p a l U I W , \ J l 4 U < U & j r V / 1 U I V I W I i U W l l t g , V T I I W U J ^ I U J L f l W W U U l U U V / p i l W l i . p u i ^ l l L , ^ l l l l u , L l l V / L l l U l \ J l O l O l ^ l , Q U l l L \ J l U t l U l ^ ,

niece or nephew, grandparent, grandchild, father-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 Part/' means (I) all executive officers of the Disclosing Party listed in Section H.B.l .a., ifthe Disclosing Party is a corporation; all partners of the Disclosing Party, ifthe Disclosing Party is a general parmership; all general partners and limited parmers 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 ofTicers 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 direclor, 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" wilh an elected city official or department head?

[ ] Yes [X] No

Ifyes, please identify below (I) the name and title of such person, (2) the name of the legal eniity to which such person is connected; (3) the name and title of the elecied 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

EXHIBIT A TO CITV OF CHICAGO

ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT FOR

PRESENCE RHC CORPORATION

OfBctr/Director Name Title Role

Sandra Bruce President and Chief Executive Officer

Member, Board of Directors

Officer and Director

Guy Wiebking Member, Board of Directors Director

Haven Cockerham Member, Board of Directors Director

Bruce Hamory, M.D. Member, Board of Directors Director

Mark Hanson Member, Board of Directors Director

Thomas R. Haberty, M.D. Member, Board of Directors Director

Sister Patricia Ann Koschalke, CSFN

Member, Board of Directors Director

Sister Clara Frances Kusek, CR.

Member, Board of Directors Director

Marsha Ladenberger Member, Board of Directors Director

Laurie Lafontaine Member, Board of Directors Director

Sister Teny Maltby, RSM Member, Board of Directors Dircclor

Susan McDonough Member, Board of Directors Director

Victor Orler Member, Board of Directors Direclor

Kent Russell Member, Board of Directors Director

Jose Santiago, M.D. Member, Board of Directors Director

Oflicer/Dlrector Name Tide Role

Thomas Settles Member, Board of Directors Director

Sister Mary Shinnick, OSF Member, Board of Directors Director

Sister Evelyn Varboncocur, SSCM

Member, Board of EHrectors Director

James Winikales Member, Board of Directors Director

(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose ofthis page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)

RECERTinCATION

Generally, for use with City Council matters. Not for City procurements unless requested.

This recertification is being submitted in connection with ''h.-j 'n]<. J h y h n j i-- t <\pCYhcy\f' [identify the Matter]. Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) warrants that all certifications and statements contained in the Disclosing Party's original EDS arc true, accurate and complete as of the date fumished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.

(Print or type legal name ofDisclosing Party) Date: _ l o l l o / a Q l ^

(sigrihere)

Print or type name of signatory:

_<(eat\nte. C. Frey Title of signatory:

Corporal .V'tfWir

Signed and swom to before me on [date] / 0 /D - / 3 by

-JeixriKltgy C - F r f t ^ at ( oo/c County, / Lii OlS>[state].

XyvUU' / /-<<- ^LO.yg6r> - g>^Notary Public.

Commission expires:_

Ver. 11-01-05

OFRCIAL SEAL

NOTARY PUBUC. STATE OF mmntR

CITVOFCHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name of ihc Disciosing Party submitting this EDS. Include d/b/a/ if appticabie:

Presence Health Network

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applicant

OR 2. ( ] a legal entity holding a direct or indirect interest in the Anplicant, State the legal name of Lhe

Applicant in which the Disclosing Party holds an interest: OR

3. pq a legal entity with a right of control (see Section II.B. 1.) State the legal name of the entiiy in which the Disclosing Party holds a righl of control: inc corpor.tton

Prep«nce Salnta Mary aod Elizabeth Madlctl Ccntar

B. Business address ofthe Disclosing Parly: 7435 West Ta lco t t Avenue

Chicago, I L 60631

j u l i e . r o k n i c h ®

C. Telephone: (773) 792-5269 p^^: Email: reshealthcare.org

D. Name of contact person: J u l i e Roknich _ .

E. Federal Employer Identification No. (if you have one):

F. Brief description of contract, transaction or other undertaking (referred io below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Skybridge Easement f o r an e x i s t i n g skybridge on the 2200 block of W. D i v i s i o n

G. Which City agency or department is requesting this EDS? Chicago Dept. of Transportat ion

If the Matter is a contract being handled by the City's Departmeni of Procurement Services, please complete the following:

Specification H and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION I I - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party: ] Person ] Publicly registered business corporation J Privately held business corporation ] Sole proprietorship ] General partnership ] Limited partnership ] Trust

[ } Limited liability company [ ] Limited liability partnership I ] Joint venture

Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

pq Yes [ ] No [ 1 Other (please specify)

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

I l l i n o i s

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

[ ] Yes t ] No pq N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of tbe entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there arc no such members, write "no members." For trusCs, estates or other similar entities, list below tbe legal titleholder(5).

If the entity is a general partnership, limited partnership, limited liabiiily company, limited liability partnership or joint veniure, list below the name and title of each general partner, managing member, manager or any olher person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below musl submit an EDS on its own behalf.

Name Title For l i s t of executive o f f i c e r s and dire c t o r s see Exhibit A

No members

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a tmst, estate or other similar enfity. If none, state "None." NOTE; Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the Disclosing Party

SECTION I I I ~ BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS

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

[ ] Yes pq No

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

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as tbe nature ofthe relationship, and tbe 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 tbe 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: ( I j 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 tbe Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosurc is required or make the disclosure.

Page 3 of 13

Name (indicate whether retained or anticipated to be retained)

None

Business Relationship to Disclosing Party Fees (indicate whether Address (subcontractor, attorney, paid or estimated.) NOTE:

lobbyist, etc.) "hourly rale" or "t.b.d." is not an acceptable response.

(Add sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes I ] No pq No person directly or indirectly owns 10% or more of the Disclosing Party.

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

( jYes [ ] N o

B. FURTHER CERTIFICATIONS

I . Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which tbe Applicant should consult for defined terms (e.g., "doing business") and legal requirements), ifthe Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then tbe 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, if the Disclosing Party is a legal entiiy, all of those persons or entities identified in Section ILB.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 lo obtain, or performing a public (federal, stale or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; thefl; 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 govemmental entity (federal, stale or local) with committing any ofthe offenses set forth in clause B.2.b. ofthis Seciion V;

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

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

3. The cenifications in subparts 3, 4 and 5 concem:

• the Disclosing Pany; • any "Contractor" (meaning any contractor or subcontractor used by tbe Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Seciion IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affihated Entity" (meaning a person or entiiy that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disciosing Parly, or is, with the Disclosing Party, under common coatrol of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity lo do business with federal or state or local govemment, including tbe City, using substantially the same management, ownership, or principals as the ineligible entity); with respeci to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

olher official, agenl or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of tbe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Coniractor, nor any Affiliated Entity of either the Disclosing Party or any Coniractor 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 wilh the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom of competition by agreemeni lo 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 stale 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 slate 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 mainiained by the Office of Foreign Assets Control ofthe U.S. Departmeni of the Treasury or the Bureau of Industry and Security of the U.S. Depariment 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 Inspecior General), 2-56 (Inspector General) and 2-156 (Govemmental 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:

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 ihe best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 12-monlh period preceding Ihe execution dale of this EDS, an employee, or elected or appointed official, ^ f - * u ^ r^: . . , ..F r^u nr. . .^. . . . . — H K T / A >* ^ >,\ \ji kiiw ^lijr Ul v^iiiwagu ^11 11WU&, liiui^aic wiiil Mr/\ Ul liUJiC f .

None

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 elecied or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available lo City employees or to tbe 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 Cily recipient. None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Parly certifies lhal the Disclosing Party (check one)

[ ] is pq is not

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

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

"We are nol and will not become a predatory lender as defined in Chapier 2-32 of the Municipal Code. Wc further pledge tbat none of our affiliates is, and none of them will become, a predatory lender as defined in Chapier 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):

Page 7 of 13

Ifthe letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed thai the Disclosing Party certified lo 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 inierest in his or her own name or in the name of any other person or eniity in the Matter?

[ ] Yes ft] 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 competiiive bidding, or otherwise permitted, no City elecied official or employee shall have a financial interesi 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 tbe suit of the City (collectively, "Cily Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does nol constitute a financial interesi wiihin the meaning of this Part D.

Docs the Matter involve a City Property Sale?

[ ] Yes iq 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. Tbe 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. 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 disclosurc requirements may make any contraci entered into with the Cily 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 Parly and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during ihe slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDINO 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 Parly with respect lo the Matter: (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or if the letters "NA " or ifthe word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered underthe Lobbying Disclosurc Aci of 1995 have made lobbying contacts on behalf ofthe Disclosing Party with respect lo 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 ofany 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 statemenis and information set forth in paragraphs A . I . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in seciion 501(c)(4) ofthe Intemal Revenue Code of 1986; or (ii) il is an organization described in seciion 501(c)(4) ofthe Intemal Revenue Code of 1986 but bas not engaged and will not engage in "Lobbying Activities".

5. Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . I . through A.4. above from all subcontractors before it awards any subconU-acl and the Disclosing Party must mainuin all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to tbe City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[]Yes [ ] N o

I f "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

I ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[]Yes [ ] N o

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ 1 No

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

Page 10 of 13

SECTION VII - .ACKNOWLEDGMENTS, CONTRACT LNCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in ihis EDS will become part ofany contract or other agreement between the Applicant and the City in connection with the Matier, whether procurement. City assislance, or other City action, and are material inducemenis to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party imderstands thai il must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. Tbe City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entilies seeking Ciiy contracis, work, business, or transactions. The full text of these ordinances and a training program is available on line al 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 wilh the applicable ordinances.

C. If the City determines that any information provided in ibis 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 equily, 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 Ciiy of treble damages.

D. It is the City's policy to make this document available to the public on ils Intemet site and/or upon request. Some or all of tbe informaiion 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 Informaiion 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 againsi the City in connection with the pubiic release of information contained in this EDS and also authorizes the City lo 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 ihe City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants ihat:

Page 11 of 13

F.l. The Disclosing Parly 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 lo, all water charges, sewer charges, license fees, parking tickets, properly taxes or sales taxes.

F.2 Ifthe 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. 1. and F.2. above and will not, without the prior written consent of ihe City, use any such contractor/subcontractor that does nol provide such certifications or that the Disclosing Party has reason to believe has not provided or cannoi provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as lo any of the items in F.l., F.2. or F.3. above, an explanatory statement musi be attached lo ihis EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (I) warrants that he/she is authorized to execute ihis EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statemenis contained in this EDS and Appendix A (if applicable) arc tme, accurate and complete as of the date furnished to the City.

Presence Health Network

(PrinI or typemame of Disclosing Part

(Sig* here)

Jeannie C. Frey

(Print or type name of person signing)

Corporate Secretary (Print or type title of person signing)

Signed and swom to before me on (date) _ at r pe^k^ County, I p l — (state).

n \ r ) / C ^ ^ Notary P|r.-' ^ g ^ ^ ^

Commission expires: . I WMWniliX-fnilCPUJNM

Page 12orT3

CITV OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFRCIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which bas only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party musl disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Parmer thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the dale 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 cily department head as spiouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sisier, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughtcr-in-law, stepfather or stepmother, stepson or stepdaughter, slepbrolher 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., ifthe 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, ifthe 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 ofTicers of die Disclosing Party; and (3) any person having more than a 7.5 percent ownership inierest 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 elecied city official or department head?

[ ] Yes [X] No

If yes, please idcnUfy below (I) the name and litle of such person, (2) the name of the legal entity to which such person is connected; (3) the name and litle 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

EXHIBIT A TO a X Y o r CHICAGO

ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT FOR

PRESENCE HEALTH NETWORK

OfOcer/Dlrector Name Title Role

Sandn Bruce President and Chief ExecBU've Officer

Member, Board of EHrectors

OfRcer and Director

Ouy Wiebking ChairpenoR, Bpatd of Directors

Director

Haven Cockerham Member, Boaid of Directors Director

Brwe Hatnory, M.D. Member, Board of Directors Director

Mark Hanson Member, Board of Directors Director

Thomas R. Hubcrty. M.D. Member, Board of EHrectors Director

Sister Patricia Ann Koschalke, CSFN

Member, Boaid of Directors Director

Sister Clara Frances Kusek, CR.

Member. Board of Directors Director

Marsha Ladenberger Member, Boud of Directors Director

Laurie Lafontaine Member, Board of Diicclon Director

Siiter Terry Maltby, RSM Member, Board of Dicecton Director

Susan McDonough Member, Board of Directors Director

Victor Orler Member, Board of I>irecton Direclor

Kent Russell Member, Board of Directors Director

Jose Santiago, MJ>. Member, Board of Directors Director

Of&ar/Dircctor Name THIe Role

Member, Board of Directors Director

Sister Mary Shinnick, OSF Member, Board of Direaors Director

Sister Evelyn Varboncocur, SSCM

Member, Board of Directors Director

James WinOcatcs Member, Board of Directors Diiector

(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose ofthis page is for you to recertify yo'jr EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with conect or conected information)

RECERTIFICATION

Generally, for use with City Council matters. Not for Ciiy procurements unless requested.

This recertification is being submitted in connection with ^'^fTvyc Sk-, boJcje (sASini( in j [identify the Matter]. Under penalty of perjury, the person signing below: (1) wanants that he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) wanants that all certifications and statements contained in the Disclosing Party's original EDS are tme, accurate and complete as ofthe date fumished to the City and continue to be true, accurate and complete as ofthe date of this recertification, and (3) reaffirms its acknowledgments.

(Print or type legal name ofDisclosing Party) Date; \C^\(\jm'(h

(sign hare)

Print or type name of signatory;

Title of signatory;

1&

Signed and swom to before me on [date] IQ ' lo - / 3 . by vJpnnnig. / C Prety at ^ypoK County, I I I / n o ^ [state].

/ L c ^ L . t J ' ^ L l k J z J L ^ U Q ^ Notary Public.

Commission expires: I? / alio j/ ~^

Vcr ll-t l l-05

OFFICULSEAL OUNEHABERKAhP

MOTAHY PUBUC - 8TAT1 Of UWOS MVCO«M88XMGim08Wl7

11%»l>lWI>«» n .1 »„>, M ^ J

City of Chicago

Office of the City Clerk

Document Tracking Sheet

R2013-878

Meeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

10/16/2013

Arena (45)

Resolution

Support of Class 6(b) tax incentive for 4227 North Knox LLC

Committee on Economic, Capital and Technology Development

RESOLUTION FOR RENEWAL OF CLASS 6(B) REAL ESTATE TAX INCENTIVE

FOR THE BENEFIT OF 4227 NORTH KNOX LLC, AND

REAL ESTATE LOCATED GENERALLY AT 4227 NORTH KNOX AVENUE AND 4155 NORTH KNOX AVENUE

IN CHICAGO, ILLINOIS PURSUANT TO COOK COUNTY, ILLINOIS

REAL PROPERTY ASSESSMENT CLASSIFICATION ORDINANCE

WHEREAS, the Cook County Board of Commissioners has enacted the Cook County Real Property Assessment Classification Ordinance, as amended from time to time (the "Ordinance"), which provides for, among other things, real estate tax incentives to property owners who build, rehabilitate, enhance and occupy property which is located within Cook County and which is used primarily for industrial purposes; and

WHEREAS, the City of Chicago (the "City"), consistent with the Ordinance, wishes to induce industry to locate, expand and remain in the City by supporting financial incentives in the form of property tax relief; and

WHEREAS, 4227 North Knox LLC, an Illinois limited liability company (the "Applicant"), is the owner of certain real estate located generally at 4227 North Knox Avenue and 4155 North Knox Avenue, Chicago, Illinois 60641 as further collectively described on Exhibit A hereto (the "Subject Property") and has constructed an approximately 47,000 square foot industrial facility thereon; and

WHEREAS, the Applicant has leased the Subject Property to Independent Mechanical Industries, Inc., an Illinois corporation; and

WHEREAS, on June 4, 2003 the City Council of the City enacted a resolution supporting and consenting to the Class 6(b) classification of the Subject Property by the Office of the Assessor of Cook County (the "Assessor"); and

WHEREAS, the Assessor subsequently granted the Class 6(b) tax incentive in connection with the Subject Property; and

WHEREAS, the Applicant has filed an application for renewal of the Class 6(b) classification with the Assessor pursuant to the Ordinance; and

WHEREAS, the Subject Property is located within the City of Chicago Enterprise Zone No. 4 (created pursuant to ttie Illinois Enterprise Zone Act, 20 ILCS 665/1 et seq.. as amended, and pursuant to an ordinance enacted by the City Council of the City, as amended), and the purpose of the Enterprise Zones are also to provide certain incentives in order to stimulate economic activity and to revitalize depressed areas; and

WHEREAS, it is the responsibility of the Assessor to determine that an application for a Class 6(b) classification or renewal of a Class 6(b) classification is eligible pursuant to the Ordinance; and

WHEREAS, the Ordinance requires that, in connection with the filing of a Class 6(b) renewal application with the Assessor, an applicant must obtain from the municipality in which such real estate is located a resolution expressly stating that the municipality has determined that the Industrial use of the property is necessary and beneficial to the local economy and that the municipality supports and consents to the renewal ofthe Class 6(b) classification; now therefore,

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

SECTION 1: That the City determines that the industrial use of the Subject Property is necessary and beneficial to the local economy in which the Subject Property is located.

SECTION 2: That the City supports and consents to the renewal of the Class 6(b) classification with respect to the Subject Property.

SECTION 3: That the Clerk of the City of Chicago is authorized to and shall send a certified copy ofthis resolution to the Office ofthe Cook County Assessor, Room 312, County Building, Chicago, Illinois 60602 and a certified copy ofthis resolution may be included with the Class 6(b) renewal application filed with the Assessor by the Applicant, as applicant, in accordance with the Ordinance.

SECTION 4: approval.

That this resolution shall be effective immediately upon its passage and

John Arena Alderman, 45" Ward

EXHIBIT A

Legal Description of Subject Property:

Those parts ofthe West Vz ofthe Southwest % of Section 15, Township 40 North, Range 13 East of the Third principal Meridian, of lot 4 in block 6 in Dickenson's subdivision of that part of the North 14 of the Southwest % of said section 15 lying west of Chicago and Northwestern Railway Co's Land, excepting right of way of Chicago, Milwaukee and St. Paul Railway Company, ofthe vacated street lying westerly of and adjoining said lot 4, and that part of North Knox Avenue vacated by ordinance passed January 7, 1941, described as follows:: Beginning at a point ofthe Easterly line of North Knox Avenue, as dedicated by plat recorded in the Recorder's Office of Cook County, Illinois, as document number 12457890, which is 826.62 feet Southeasterly from the angle in the East line of said dedicated street, which angle is 314.84 feet south of the south line of West Montrose Avenue, and running thence Northeastwardly along a line perpendicular to said Easterly line, a distance of 173.53 feet to a point 19.43 feet Southwesterly from the point of intersection of said perpendicular line with a line 19.50 feet (measured perpendicularly) Westeriy from and parallel to the Westerly line of the lands of Chicago and Northwestern railway company; thence Southerly, a distance of 177.34 feet to a point on the above mentioned parallel line which is 179.26 feet Southerly from the above mentioned point of intersection of said perpendicular lines; thence Southeriy along the hereinbefore mentioned parallel line. A distance of 51.14 feet; thence Southwardly along the arc of a circle having a radius of 469.84 feet, convex Easterly and tangent to the last above mentioned parallel line, a distance of 88.72 feet to a point of tangency with a line 19.50 feet West of and parallel to the West line of said lands of Chicago and Northwestern Railway Company (Said West line of Railway lands being a line 113.22 feet West of and parallel to the East line of the West Vz of the Southwest % of said section 15; thence South along said line which is 19.50 feet West of said West line of Railroad lands, a distance of 396.58 feet to the Easterly line of said North Knox Avenue, as dedicated by plat recorded in the Recorder's Office of Cook County, Illinois as document number 12615197; thence Northwestwardly along the Easterly line of said North Knox Avenue, as established by said plats of dedication and said ordinance of vacation, a distance of 687.29 feet to the point of the beginning, in Cook County, Illinois.

Permanent Real Estate Tax Index Numbers (PINS) for the Subject Property:

13-15-306-020-000

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:

4227 North Knox, L L C

Check ONE ofthe following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. §(] 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: 4227 North Knox

Ctiicago, IL 60641

C. Telephone: <773) 282-4500 Fax: (773) 282-2046 Einailioe''ey''ol«*s@independentmech.com

D. Name of contact person: Joseph P. Reynolds _.

E. Federal Employer Identification No. (if you have one}

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Appiication for C lass 6 (b) rencvyal 4227 North Knox and 4155 North Knox

Department of Housing & G. Which City agency or department is requesting this EDS? Economic Development

Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # N/A and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature ofthe Disclosing Party: ] Person pC| Limited liability company ] Publicly registered business corporation [ ] Limited liabihty partnership ] Privately held business corporation [ ] Joint venture ] Sole proprietorship [ ] Not-for-profit corporation ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? ] Limited partnership [ ] Yes [ ] No ] Trust [ ] Other (please specify)

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

Illinois

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

[ ] Yes [ ] No N N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, hst below the legal titleholder(s).

Ifthe entity is a general partaership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on ils own behalf.

Name Title Joseph P. Reynolds Manager

John M. Reynolds Manager

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Mimicipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address

Joseph P. Reynolds 41SS N. Knox, Chicago, IL

Percentage Interest in the Disclosing Party

35%

John M. Reynolds 4155 N. Knox, Chicago, IL 65%

SECTION i n ~ BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICLALS

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

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or eniity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain v.'hether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether retained or anticipated to be retained)

N/A

Business Relationship to Disclosing Party Address (subcontractor, attomey,

lobbyist, etc.)

Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "tb.d." is not an acceptable response.

(Add sheets i f necessary)

^ ] Check here ifthe Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[JYes No [ J No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ J Yes [ J No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which fhe Applicant should consult for defined terms (e.g., "doing business") and legal requirements), ifthe 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 I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below. I certify the above to be true.

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 perfonning a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitmst 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 govemmental 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, withui 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 conceming environmental violations, instituted by the City or by the federal government, any state, or any other unit of local govemment. I cerfify the above to be true.

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Parly in

coimection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation; interlocking management br ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially lhe same management, ownership, or principals as the ineligible eniity); 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, wilh the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Eniity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respeci to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of tlie City, the State of Illinois, or any agency of the federal govemment or of any state or local goverament in the United Stales of America, in that officer's or employee's official capacity;

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

c. made an admission o f such conduci described in a. or b. above that is a matter of record, but have nol been prosecuted for such conduci; or

d. violated the provisions of Municipal Code Section 2-92-610 (Living Wage Ordinance). I certify the above to be true.

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 govemment 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 stale or of the Uniied States of America lhal contains the same elements as the offense of bid-rigging or bid-rotating.

I certify the above to be true.

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 Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

I certify the above to be true.

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) of the Municipal Code.

I certify the above to be true.

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

None

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, tbe 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 lo City employees or to the general public, or (ii) food or drink provided in the course of official Cily business and having a retail value of less than $20 per recipieni (if none, indicate with "N/A" or "none"). As lo any gift hsted below, please also list the name of the City recipient.

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [)g is nol

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliales 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 ofthe privilege of doing business with the City."

I f the Disclosing Parly 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);

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 ofthe Municipal Code have the same mearungs 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 enlily in the Matter?

[ ] Yes pq No

NOTE: I f you checked "Yes" lo Item D.L, proceed lo hems 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 interesi 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 lo the Cily, 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 properly taken pursuant to the City's eminent domain power does not constitute a financial uiterest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

[ ] Yes [ ] No

3. I f you checked "Yes" lo 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 Parly 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 insiuance policies during the slavery era (including insurance policies issued to slaveholders lhal 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 foimd records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Parly verifies that the following constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section VI . Kthe Matter is not federally funded, proceed lo Section VII. For purposes of this Seciion VI, lax 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 entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Parly with respect to the Matter: (Add sheets if necessary):

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt lo 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 ofCongrcss, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering inlo any cooperative agreement, or lo 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 stalements 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. I f the Disclosing Party is the Applicant, the Disclosing Parly 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 mainlain all such subcontractors' certifications for the duration of the Matier and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matier is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing al the outset of negotiations. N/A

Is the Disclosing Party the Applicanl?

[ J Yes [ J No

If "Yes," answer the three questions below;

1. Have you developed and do you have on file affirmative action programs pursuant lo applicable federal regulations? (See 41 CFR Part 60-2.)

[ J Yes [ J No

2. Have you filed wilh the Joint Reporting Committee, the Director ofthe Office of Federal Contraci Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ J No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ 1 Yes [JNo

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

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SECTION V I I -- ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Apphcant and the City in connection with the Matter, whether procurement. City assislance, or other Cily action, and are material inducements to fhe City's execution ofany contract or taking other action with respect to the Matter. The Disclosing Party understands thai it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the Cily'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 lhal any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection wilh which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contraci or agreement (if nol rescinded or void), at law, or in equity, including ternunating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the Cily. Remedies at law for a false statement of material fact may include incarceration and an award to the Cily of treble damages.

D. It is fhe City's policy to make this document available lo the public on its Iniemet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments lo this EDS may be made available lo the public on the Internet, in response to a Freedom of Information Act requesl, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which i l may have against the City in connection with the public release of information contained in this EDS and also authorizes the City lo verify the accuracy of any information submitted in tiiis 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 lo the lime the City takes action on the Matter. Ifthe Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subjectto Article I of Chapter 1-23 of the Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), tlie informaiion provided herein regarding eligibility musl 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:

Pageil 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, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes. I certify the above to be true.

F.2 If the Disclosing Party is the Applicanl, 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. I certify the above to be true.

F.3 If the Disclosing Party is the Applicanl, 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, withoul 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 nol provided or cannot provide tmthful certificalions. 1 certify the above to be true.

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 tme, accurate and complete as of the date fumished to^he City.

4227 North Knox, LLC

type name of Disci

A (Sign here)

Uelseph P. Reynolds

(Print or type name of person signing)

Manager

(Print or type title of person signing)

Signed and sworn td before me on (date) j O f ^ / J 3 at L>5~6k. County, ' ^ s f M i n A i (slate).

"OFFIOALSEAL" Notary Public. | MARIAV GRANADOS

Notary Public. State of Illinois T . - , Commission expires: ^ " l / ^ D / G I S S S ^ ^ S s S S ^

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party musl disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" wilh any elecied city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Parly or any "Applicable Party" or any Spouse or Domestic Partner thereof is related lo 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 imcle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, slepfether 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 n.B.l.a., i f the Disclosing Parly is a corporation; all partners of the Disclosing Party, ifthe Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a hmited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a Hmited liability company; (2) all principal oflicers 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 direclor, 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 departmeni head?

[ J Yes [XJ No

Ifyes, please identify below (1) the name and title of such person, (2) the name of the legal entity lo which such person is coimected; (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

SECTION I - GENERAL INFORMATION

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

independent Mechanical Industries, Inc.

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. M the Applicant

OR 2. [ J a legal entity holding a direct or indirect interest in the Applicant Stale the legal name of the

Applicant in which the Disclosing Party holds an inierest: 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 righl of control:

B. Business address of the Disclosing Party: 4155 North Knox

Chicago, IL 60641

C. Telephone: (773) 282-4500 Fax: (7731 282-2046 Emailioereynolds@independentmech.com

D. Name of contact person: Joseph P. Reynolds

E. Federal Employer Identification No. (if you have one}

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Application for Class 6 (b) renewal 4227 North Knox and 4155 North Knox

Department of Housing & G. Which City agency or depariment is requesting this EDS? Economic Development

Ifthe Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # N/A and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION I I - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

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

Illinois

3. For legal entities nol organized in the State of Illinois: Has the organization registered to do business in the Stale of Illinois as a foreign entity?

[ J Yes [ ] No N N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and tities of all executive officers and all directors ofthe entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f there are no such members, write "no members." For tmsts, estates or other similar entities, list below the legal tilleholder(s).

I f the entity is a general partnership, limited partnership, lunited 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 entiiy tisted below must submit an EDS on its own behalf.

Name Title Joseph P. Reynolds President

John M. Reynolds CEO

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% ofthe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar eniity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicanl which is reasonably intended lo achieve full disclosure.

Name Business Address

Joseph P. Reynolds 4155 N. Knox, Chicago, IL

Percentage Interest in the Disclosing Party

33%

John M. Reynolds 4155 N. Knox, Chicago, IL 63%

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

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

[JYes MNo

Ifyes, please identify below the name(s) of such Cily elected official(s) and describe such relalionship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Parly musl disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entiiy whom the Disclosing Parly has retained or expects to retain in connection wilh the Matier, as well as the nature of the relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Parly is nol required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyisi" means any person or eniity 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 entiiy any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether retained or anticipated to be retained)

N/A

Business Relationship lo Disclosing Parly Address (subconlractor, attomey,

lobbyist, etc.)

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

(Add sheets i f necessary)

M Check here if tiie Disclosing Party has nol retained, nor expects to retain, any such persons or entities.

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Seciion 2-92-415, substantial owners of business entities that contraci wilh 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 obhgalions by any Illinois court of competent jurisdiction?

[JYes p(] No [ J No person directly or indirectiy owns 10% or more of the Disclosing Party.

I f "Yes," has the person entered inlo 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 I")(which the Applicanl should consult for defined terms (e.g., "doing business") and legal requirements), ifthe 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 Applicanl nor any controlhng person is currentiy 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 fhe Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below. I certify the above to be true.

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 unil of governmenl;

b. have not, within a five-year period preceding the date ofthis EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaciion; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false stalements; or receiving stolen property;

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

d. have nol, 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 dale of this EDS, been convicled, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceming environmental violations, instituted by the Cily or by the federal government, any state, or any other unit of local govemment. I certify the above to be true.

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

• the Disclosing Parly; • any "Contractor" (meaning any coniractor or subcontractor used by the Disclosing Party in

connection with the Matier, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entiiy" (meaning a person or entity that, directly or indirectiy: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business eniity lo do business wilh federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); wilh respect to Contractors, the term Affiliated Entity means a person or entiiy that directiy or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or eniity; • any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entiiy, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agenis").

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 conbract or engagement in coimection with the Matter:

a. bribed or attempted lo bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the Stale of Illinois, or any agency ofthe federal government or ofany slate or local governmenl in the United Stales of America, in that officer's or employee's official capacity;

b. agreed or colluded wilh olher bidders or prospective bidders, or been a party to any such agreemeni, or been convicted or adjudged guilty of agreemeni 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). I certify the above to be true.

4. Neither the Disclosing Party, Affiliated Enlily or Coniractor, or any of their employees, officials, agenis or partners, is barred from contracting with any unit of stale 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-rotaling in violation o f 720 ILCS 5/33E-4; or (3) any similar offense ofany slate or of the Uniied States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

I certify the above to be true.

5. Neither the Disclosing Party nor any Affiliated Eniity is listed on any of the following lists maintained by the Office of Foreign Assets Control o f 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 Designaied Nationals List, the Denied Persons Lisl, the Unverified List, the Eniity Lisl and the Debarred List.

I certify the above to be true.

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.

I certify the above to be true.

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

Ifthe letters "NA," the word "None," or no response appears on the lines above, i lwi l l be conclusively presumed that the Disclosing Party certified to the above stalements.

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

None

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, al any time during the 12-month period preceding the execution date of this EDS, lo an employee, or elected or appointed official, of the City of Chicago. For purposes ofthis statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the Cily recipieni.

None

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ J is [X] is not

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

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

"We are nol and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliales is, and none of them will become, a predatory lender as defined in Chapier 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."

Ifthe Disclosing 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 wiihin the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary):

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 thai 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 inierest in his or her own name or in the name of any otiier person or entity in the Matier?

[ J Yes pq 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 pursuani to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interesi 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 pursuani to the City's eminent domain power does nol constitute a financial interest wiihin 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 tbe 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 furiher 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. Ifthe Disclosing Parly checks 2., the Disclosing Parly 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 eniered inlo with the Cily in connection with the Matter voidable by the Cily.

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 investmenls or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage lo 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 thai the following constitutes full disclosure of all such records, including the names ofany and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2. The Disclosing Party has nol 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 lo 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 ofCongrcss, or an employee of a member ofCongrcss, 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 accxuracy 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 seciion 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 nol engaged and will nol engage in "Lobbjang Activities".

5. Ifthe Disclosing Party is the Applicant, the Disclosing Party musl 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 musl maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the Cily upon request

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

I f the Matier is federally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following informaiion with their bids or in writing at the outset of negotiations. N/A

Is the Disclosing Party the Applicant?

[ J Yes [ J No

I f "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ J Yes [ J No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ J Yes t J No

3. Have you participated in any previous contracis or subcontracts subject to the equal opportunity clause?

[ J Yes [ J No

I f you checked "No" to question 1. or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contraci or olher agreement between the Applicanl and the City in connection with the Matier, whether procurement. City assislance, or olher City action, and are material inducements to the City's execulion of any contract or taking other action with respect to the Matter. The Disclosing Party understands that i l musl comply wilh 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 contracis, work, business, or transactions. The full text of these ordinances and a training program is available on line al www.citvofcbicago.org/Ethtcs, and may also be obtained from the Cily's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully wilh the applicable ordinances.

C. I f the City determines lhal any informaiion provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submilled may be rescinded or be void or voidable, and the City may pursue any remedies under the contraci or agreemeni (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining lo allow the Disclosing Party to participate in olher transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the Cily of treble damages.

D. It is the City's policy to make this document available to the public on ils 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 ofany information submitted in this EDS.

E. The informaiion 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 respeci to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept curreni for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Parly represents and warrants that:

Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any lax administered by the Illinois Department of Revenue, nor are the Disclosing Party or ils Affiliated Entities delinquent in paying any fine, fee, tax or olher 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. I certify the above to be true.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entilies 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,

i certify the above to be true.

F.3 Ifthe Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection wilh the Matier 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 Parly has reason to believe has not provided or cannot provide Imthful certifications.

I certify the above to be true.

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 lo 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 stalements contained in this EDS and Appendix A (if applicable) are tme, accurate and complete as ofthe dale furaished lo the City.

INDEPENDENT MECHANICAL INDUSTR

sign here)

Josdpfi P. Reynolds (Print or type name of person signing)

President

(Print or type title of person signing)

Signedand sworn to before me on Male) at L J ^ l A ^ County, \ J i ! i £ u c ^ \ (slate).

7 y < ^ - ^ ^ ^ X / f e ^ : ; ^ Noiary Public. F ^ ^ F I C ^ ^ S E A L " ^ ^ ( J I M/\RIA V. GRANADOS

^ 1 ^ / -5 / ; / \ Notary Public, State of Illinois | Commission expires: e ^ / //(>dO/^ . | My Commission Expires 02W9/2016|

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND APTTDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CTTY OFFICULS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elecied 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 Paitner 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 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 SecUon ILB.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 linuled partners ofthe Disclosing Party, ifthe Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, ifthe 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 interesi 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 currentiy have a "famiUal 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 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

Office of the City Clerk

Document Tracking Sheet

Or2013-609

IVIeeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

10/16/2013

Colon (35)

Order

Landmark fee waiver for property at 2774 N Milwaukee Ave

Committee on Zoning, Landmarks and Building Standards

ORDER

WHEREAS, Section 2-120-815 ofthe Municipal Code provides that the Chicago City Council may by passage of an appropriate order waive any fees charged by the City for any permit for which approval of the Commission on Chicago Landmarks (the "Commission") is required, in accordance with chapter 2-120 of the Municipal Code; and

WHEREAS, the permits identified below require Commission approval, in accordance with Section 2-120-740 of the Municipal Code; now, therefore,

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

SECTION 1. The foregoing recitals are hereby adopted as the findings of the City Council.

SECTION 2. The Commissioner of the Department of Buildings, the Commissioners of the Departments of Environment and Fire, the Director of the Department of Revenue, and the Zoning Administrator are hereby directed to issue those permits for which approval of the Commission on Chicago Landmarks is required pursuant to Chapter 2-120 of the Municipal Code free of charge, notwithstanding any other ordinances of the City Council to the contrary, for the property at:

Address: 2774 North Milwaukee Avenue ("Property") District/Building: Milwaukee-Diversey-Kimball District

for work generally described as: Rehabilitation and rooftop addition to an existing 2-story building, to include ground level commercial retail and upper level residential space.

Owner: Fox Chicago, LLC Owner's Address: 1110 Pleasant Street City, State, Zip: Oak Park, Illinois 60302

SECTION 3. The fee waiver authorized by this Order shall be effective from October 1, 2013 through October 1, 2015, and shall not apply to additional developer service fees, stop-work order fees or any fines.

SECTION 4. That the permit purchaser for the Property shall be entitled to a refund of city fees for which it has paid and which are exempt pursuant to Section 1 hereof.

SECTION 5. This order shall be in fia^Cand ect upon its passage.

' ^RcyCoIon Alderman, 35"

NOTE: This is NOT a permit nor does it constitute a Letter of Approval for the above described work. A permit application for the work must be approved by the appropriate City department(s) as well as the Commission on Chicago Landmarks for this permit fee waiver, subject to City Council approval, to be valid.

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 ofthe Disclosing Party:

Person Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)

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

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 [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the ful l names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing niember, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name/^ ^ y. 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

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

Name Business Address Percentage Interest in the

n n r— n A - / DisclosingParty

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

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

[ ] Yes ^ N o

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 OF SUBCONTRACTORS AND O T H E R R E T A I N E D PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyisf means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyisf also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)

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

(Add sheets i f necessary)

m^^eck here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

S E C T I O N V - C E R T I F I C A T I O N S

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ ] Yes [ ] N o

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, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I . B . l . ofthis 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. ofthis 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 ofthis EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

• any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency of the federal government or ofany state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

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

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l 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 12-month 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").

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

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [wfis'not

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

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

"We are not and wil l 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 wil l 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):

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 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 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? .

[ ] Yes K N O

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. 1., 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. 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 wi l l 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

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

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

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 ful l 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 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 wi l l 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 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 ofCongrcss, an officer or employee ofCongrcss, or an employee of a member of Congress, in connection with the award ofany 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 wil l 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 wil l not engage in "Lobbying Activities".

5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

I f "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Y e s [ ] N o

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

I f you checked "No" to question 1. or 2. above, please provide an explanation:

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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 INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS wil l 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 ful l 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 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 ofany 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 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: Ifthe 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.

C E R T I F I C A T I O N

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.

(Print or type name of

(Sign here)

. f : ^ j ^ h i j k . 4 d - M j ^ _ (Print or type name of person signing)

Ih Js c- _ (Print or type title of person signing)

Signed and sworn to before me ontdate) al C o u n ^ _//^;;^=^__ _ (state).

Commission expires:

Notary Public.

Page 12 of 13

OFICIALSEAL ROBERT DBJEGLER

MOT«Y PUBLIC - STATE OF ILLINOIS MY COMMISSION EXP«ES:08y21/17

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"AppUcable Party" means (1) all executive officers ofthe Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; 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, ifthe Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief fmancial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

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

[ ] Yes ]p)<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 cormected; (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

SECTION n - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of tbe Disclosing Party: [ ] Person [ ] Limited liability company [ ] Pubiicly registered business corporation [ ] Limited liability partnership 1^ Privately held business corporation [ ] Joint venture [ } Sole proprietorship [ ] Not-for-proftt corporation [ ] General partnership (Is the not-for-profit corporation also a 501 (c)(3))? [ ] Limited partnership [ } Yes [ ] No [ ] Trust [ ] Other (please specify)

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

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

[]Yes []No [)N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-proftt corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titIefaohIer(s).

Ifthe entity is a general partnership, limited partnership, limited liability company, limited liabiHty partBersfa D co* jetol veBture, Hst below the name and tilte of each goteral partner, managing member, manager or any other persoa er entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity Ksted below must submH aa EDS on its own behalf.

Name

2. Please provide the foUowing information conceming each person or entity having a direct or indirect beneficial mterest (including ownership) in exeess of 7.5% of ^e Disclosing Party. Examples of such an interest include shares in a corporation, partoergbip interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2*154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the — ^ ,1 Disclosing Party

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

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

[ ] Yes ^ N o

If yes, please identify below the n3me(s) of such City elected officiates) and describe such relationship(s):

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retamed 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 te influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-fH'olit 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.

Ifthe Disclosing Party is uncertain whether a disclosure is requhfed under this Sectioa, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attomey, paid or estimated.) NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Ad^sbeets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

Has any person who directly or indirectly owns 10% or nK>re of the Disclosing Party been declared in arrearage on any child support obligations by any Itlinois court of competent jurisdiction?

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

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

[ 1 Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article l")(which the Applicant should consult for dellaed terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is tfie A^lieam imd is doing business with the City, then the Disclosing Pstfty certifies as follows: (i) neither the Af^ticant nor aay coatretlmg person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision Ibr, any criminal offense iavotviag actual, attempted, or conspiracy to commil bribery, theft, firaud, forgery, perjury, dishonesty or deceit against an officer or en itoyee of die Cily or any sist^ ag^icy; and (ii) l e Af^lieant understands and acknowledges tfiat compliance with Article I is a eoattauing requirement for doing business with tbe 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 . ofthis EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded £rom any transactions by any federal, state or local unit of govemment;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminai offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federai, 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 faise statements; or receiving stolen property;

e. are not presently iadicted for, or criminally or civilly charged by, a goveramental entity (federal, state or local) with committing any ofthe offenses set forth in clause B.2.b. of tbis 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 defauh; a&d

e. have not, within a five-year period preceding the date ofthis EDS, been convieted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceraing environmental violations, instituted by the City or by the federal govemment, any state, or any other unit of locat goverament.

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

• the Disclosing Party; • any "Contractor" (meaning aay coatractor or subcontractor used by the Disclosing Party in

connection with the Matter, iacludmg but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained P»rties"); • any "Affiliated Entity" (meaaing a person or eatity that, directly or indirectly: controls the

Disclosing Party, is controlied by the Disclosing Party, or is, with the Disclosing Party, un<ter common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equq ment; common use ef employees; or organization of a busmess entity following the ineligibility of a business entity to d& business with federal or state or local government, inehtdiag the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Confractors, the term Affiliated Entity means a person or eatity that directly or indirectly controls the Contractor, is controlled by it, or, with the Coatractor, is under commoa control of another person or entity; • any responsible ofllcial of the Disclosing Party, any C<mtractor or any Affiliated Emity or any

other officiai, agent or employee ef the Disclosing Party, any Contractor er any Afilliated Entity, acting pursuant to the direetion or authorizatioB of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (cotlectivety "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency of the federal goverament or of any state or locai govemment in the United States of America, in that officer's or employee's official capacity;

b. agreed or colluded with other bidders or pr tspective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, m 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 Seetion 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 uait of state or local govemment as a result of engaging in or being eonvicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rototing in violation of 720 ILCS 5/33E-4; or (3) any similar offense ofany state or ofthe United States of America that contains the same elements as the offense of bid-rigging er iMd-rotating.

5. Neither the Disclosiag Ps»ty nor any AffiUated Entity is listed on any ef the following lists maintained by the Office of Foreign Assets Confrol of the U.S. Department ef tfie Treasury or the Bureau of Industry and Security of the U.S. Departm^t of Commerce or their successors: the SpeetaHy Desigaated Nationals List, tfke Denied Persons List, the Unverifled List, the Eatity List and tfie Debarred List.

6. The Disclosiag Party understands and shaH comply with the applicable requirements of Chapters 2-55 (Legislative inspector General), 2-56 (Inspector General) and 2-156 (Goveromeatal Etfiics) ef tbe Municipa! Code.

7. If the Disclosing Party is unable to certify te any of the above statements in this Part B (Fi»th^ Certifications), the Disclosing Party must exptaia below:

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

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 ofthis EDS, to an employee, or elected or appointed official, ofthe City of Chicago. For purposes ofthis statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $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.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is J/fw'not

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

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

"We are not and wili 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 tbat 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 deflned 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):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the tines above, it will be conclusively presumed that the Disctosing 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 tbis 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 ofany other person or entity in the Matter? . ,

11 Yes WNO

NOTE: If you cheeked "Yes" to Item D. 1., proceed to Items D.2. and D.3. ff you checked "No" to Item D. 1., proceed to Part E.

2. Unless sold pursuant te a process of competitive biddiag, er otherwise permitted, no City elected eflkial or employee shaH have a financial interest in bis or her own name or in the name of any other person or eatity m 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 emment domain power does not constitute a financial interest within the meaning ofthis Part D.

Does the Matter invelve a City Property Sale?

I } Yes [ ] No

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

Name Business Address Nature ef brterest

4. The Disclosiag Party further certifies that no prohibited fmancial interest in the Matter will be acquired by any City official er employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please cheek either 1. or 2. below. Ifthe Disclosing Party checks 2., the Disclosiag Party must disclose below or in an attaehmeirt te tfiis EDS all information required by paragraph 2. Failure to

Page 8 of 13

comply with these disclosure requirements may make any confract entered into with the City in connec^n with the Matter voidable by the City.

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

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

SECTION VI ~ CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of all persons or entities registered under the federal Lobbyiag 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 begias en the lines above, or ifthe tetters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons er entities registered under the Lobbying Disclosure Act of 1995 have made lobbyiag contacts on behalf ef the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent aad wili not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. I. above for his or her lobbying activities or to pay aay person or entity to influence or attempt to influence an officer or employee of any agency, as defmed by applicable federal taw, a member of Congress, an officer er employee of Congress, or an empleyee of a member of Congress, in connection with the award of any federaliy funded contract, making any federally funded grant or loan, entering iato 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 Intemal 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. Ifthe Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.l . through A.4. above from all subcoafractors before it awards any Sttbeontrset and the Disclosing Party must maintain all such subconfractors' certifications for the duration ofthe Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ 1 No

If "Yes," answer the three questioas below:

1. Have you developed and do you have on ffte 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 Federai Coafract Compliance Programs, er the Equal Emptoyment OppMtunity Commission aH reports due under the applicable filing requiremeats?

E ] Yes [ 3 No

3. Have you participated in aay previous confracts or subconfracts subject to the equal opportunity clause?

[ ] Yes [ ] No

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

Page 10 of 13

SECTION VU - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disctosing Party understands and agrees that:

A. The certifications, disciosures, and acicnowiedgments contained in this EDS wilt become part of any confract 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 atl statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City confracts, work, business, er transactions. The full text of these ordinances and a fraining program is availabie on iine at www.cityofchicaao.org/Etbics, 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. Ifthe City determines that any information provided in this EDS is false, incomplete or inaccurate, any confract or other agreement in connection with which it is submitted may t>e rescinded or be void or voidable, and the City may pursue any remedies imder the contract or agreement (if aot 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 taw for a false statement of materiat fact may inciude 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 infonnation provided on this EDS and any attachments to this EDS may be made available to the public on the Intemet, m respoase to a Freedom ef Infermatioa Act request, or otherwise. By completiag and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in conaection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy ofany 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 en the Matter. If the Matter is a confract being handled by the City's Department of Procurement Services, the Disclosing Party must update tbis EDS as the confract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Munich Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the iaformation provided herein regardiag eligibility must be kept curreat for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 Ifthe 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. 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: (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.

(Print or type name of

(Sign here)

(Print or type name of person signing)

'^s±%i^^y^-(Print or type title of person signing)

Signedand sworn to before me on (date) at ^ L S Z j L County,

Commission

(statej

Notary Public.

Page 12 of 13

ROBERT OBEOLER NOTARY PinJC • STATE OF HUNOS MY coftMssiON wt&m»r\i

CITVOFCHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFIQALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct owaership iaterest ia the AppUcaat exceediag 73 perceat. It is act to be eompleted by aay legal eatity which has only aa Indirect ownership interest ia the AppUcaat.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disctosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof cunently has a "familial relationsh )" with any elected city official or dq)artment head. A "familial relationship" exists if, as of die date tfiis EDS is signed, the Disclosiag Party or any "A|^icable Party" or any Spouse or Domestic Partner thmof is related to the mayor, any aldemian, tfie city clerk, the city treasurer or any city department head as ^use or domestic partner or as any ef the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nefdiew, gran iarent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, step&ther or stepmother, stepsim or stqidaughter, stepbtoiher or stepsister or hatf-brother or half-sister.

"Applicable Party" means (1) all executive oMcera of the Disclosing Party listed in Section ELB.La., if the EHsctosing Party is a corporation; att partners of the Disciosmg Party, if the Disclosing Party is a general p taership; all general partners and limited partaers of the EHsctosing Party, if the Disclosiag Party is a limited parmership; all managers, managing members and memliers ofthe EHsctosing Party, if the EHsctosing Party is a Hmited tiability company; (2) all principal officers of the EHsctosing Party; and (3) any person having more tfian a 7.5 percent ownership intoest in the EHsclosmg Party. "Principal oflicers" means the president, chief operating officer, executive dfrector, ciiief financial officer, treasurer or secretary of a legal entity or any po^n exercising similar authority.

Does the EHsctosing Ptfty or any "Afqpiicable Party" tsr any Spouse or Domestic Partner tfiereof currentiy have a "famiHal relatitmshqi" with an eteeited city official or department head?

[ JYes

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 comieeted; (3) tfie name and title of the eiected city official or depffitment head to whom such person has a familial relationship, and (4) the fnecise nature of such famiHal relatioi»hip.

Page 13 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

I. Indicate the nature of the Disctosing Party: ^ J Person | ^ Limited tiability company [ ] Publicly registered business corporation [ ] Limited liability partoership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501 (cX3))? [ ] Limited partoership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

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

3. For legal entities net organized in the State of Illhieis: Has the organization registered to do business in the State of Illinois as a foreign entity?

[ ] Yes [ } No [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of atl executive officers and atl directors of the entity. NOTE: For not-for-profit corporations, also list t>elow all members, if any, which are legai entities. If there are no such members, write "no members." For frusts, estates or other similar eatities, list below the legal titleholder(s).

Ifthe eatity is a geaeral partnership, limited partnership, limited liability company, limited liability p«tnershtp or joint venture, Hst below the name and title of each general partner, managing member, manager or any ether person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS en its own behalf.

Name ( » Title C ( , » * « K 1

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trast, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonabty intended to achieve full disclosure.

Name Business Address Percentage Interest in the Disclosing Party

frv.ri^r.pi'i^^. ling P{<?n^aJ/'<:^

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

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

[ ] Yes Y No

Ifyes, please identify below the name(s) ef such City elected official(s) and describe such relationsbip(s):

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subconfractor, attomey, lobbyist, accountant, eonsoltaat and any other persoa or eatity whom the EHscIosing Party has retaiaed or expects to retain in connection with the Matter, as welt as the natmre of the relationsbip, and the total amount ef tbe fiees paid or estimated te be paid. The Disctosing Pi»ty is net required to disclose employees who are paid solety through the Disclosiag Piety's regular payroH.

"Lobbyist" means any person or entity who uadertakes te iafiuence My legislative or adminisfrative action on behalf of any person or entity ether than: (1) a not-for-prelh entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person er entity any part of whose duties as an empleyee of another includes undertaking to influence any legislative or adminisfrative action.

If the Disclosiag Party is uncertain whether a disclesure is requhed under this Sectioa, the Disclosiag Party must either ask the City whether disclosure is required or make the disclesure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subconfractor, attoraey, paid or estimated.) NOTE: te be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add^eets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under Municipal Code Section 2-92-415, substantial owners of business entities that confract with the City must remain in compHance with their child support obligations throughout the cenfract's term.

Has any person who directiy 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?

[ ] Yes fli£,No "f Jfio person directiy or indirectiy owns 10% or more ofthe Disciosing Party.

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

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Munic^ial Code Chapter 1-23, Article I ("Article T'Xwhich the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), ifthe Disclosing Party submitttng 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 confrolling person is curreatly indicted or charged with, er has admitted guilt ef, er has ever been convieted of, or placed under supervision for, any criminal offense invoiving actual, attempted, or coaspiracy to commit bribery, theft, fraud, forgery, peijury, dishonesty er deceit against an officer or employee ofthe City or any sister agency; and (ii) the Appticant understands and acknowledges that compliance with Article I is a eeiMiauiag requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compiiance timeframe in Article t supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disciosing Party is a legal entity, att 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 fransactions by any federal, state or locai unit of govemment;

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 obtaia, or performing a public (federal, state or local) fransaction or contract under a public transaction; a vielation of federal or state antitrast statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destmction of records; making false statements; or receiving stolen property;

e. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federai, state or local) with committing aay ofthe e^enses set forth in clause B.2.b. ofthis Seetion V;

d. have not, within a five-year period preceding the date ef tbis EDS, had one or mere pubtic fransactions (federal, state or local) terminated for cause er default; aad

e. have not, withia a five-year period preceding the date of tfi^is EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceraing environmental viotatimis, institoted by the City or by the federal govemment, any state, or any other unit of local govemment.

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

• the Disclosing Party; • aay "Contractor" (meaning any eontractor or subconfractor used by the Disclosiag Party in

connectioB with the Matter, iactudiag but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors aad Other Retained Parties"); • aay "Affiliated Entity" (meaning a person or entity that, directly or indfrectly: confrols the

Disclosiag Party, is confroUed by the Disclosing Party, er is, with the Disctosing Party, under commoa coatrol ef aaother persoa or eatity. Indicia ef confrol mclude, without timit^iea: iatertoekiag maaagemeat or ownership; identity of interests among fam^y members, shared facilities and equipment; common use of employees; er CMganizatien of a business entity foHowing tfie ineligft>ftity of a business eatity to de busiaess with federai or state or local govemment, inehidiBg the City, using substantially tfie same n aaagemeat, ownership, or princ^ls as the iaetigtbte entity); with respect to Ceafractors, the term Affihated Entity ateaas a persoa or entity that d i r ^ ^ or iadirectly coatrols the Contractor, is coafretled by it, er, with the Coatractor, is und^ cmnmea control ef another person or entity; • any responsible official of Hks Disctosmg Party, any Coafractor or any Affiliated Entity er imy

other official, agent er employee ef the Disetosiag Party, any Coafractor or any Affiliated Ent^, acting pursuant to tbe direction er autftorization ef a responsible officiai ofthe Disctosing Party, aoy Contractor er aay AffiKated Entity (eoiteettvety "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Confractor, nor any Affiliated Entity of either the Disclosing Party or any Confractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Confractor, 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 confract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal govemment or of any state or tocal goverament in the United States of America, in that officer's or employee's official capacity;

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

c. ntade 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; er

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 govemment 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 er bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is Hsted 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 ef Commerce or their successors: the Specialty Designated Nationals List, the Denied Persoas List, the Uaverified List, the Entity List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements ef Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Goveramental Ethics) of the Municipal Code.

7. Ifthe Disclosiag Party is uaable to certify to any of the above statements in this Part B (Further Certifications), the Disciosing Party must explain below:

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. Te the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current empioyees ofthe Disctosing Party who were, at any time duriag the 12-month 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").

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-menth period preceding the exeeutioa date of tbis EDS, to an employee, or eiected or appointed officiai, of the City of Chicago. For purposes ofthis statemeat, a "gift" does not inchide: (i) anything made goneratiy available to City employees or to the general publte, or (ii) fiaod or drink provided ia the course of official City busiaess and having a retail value of less than $20 per recipient (if aone, indicate with "N/A" or "none"). As to any gift listed below, please also list the name ofthe City recipient.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ J is y^not

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

2. If tbe Disclosing Party IS a financial institution, then the Disetosiag Party pledges:

"We are not and wiN not become a predatory leader as defiaed in Ctiapter 2-32 of the Munic^al Code. We further pledge that none ef our affiliates is, and none of them wiH become, a predatory leader as defiaed ia Chapter 2-32 ofthe Munic^ai Cede. We uaderstand that beccnning a predatory lender or becomiag an affiliate of a predatory lender may resuh in the toss of the privilege ef doing busiaess with the City."

If the Disclosing Party is uaable to make this pledge because it or any of its affiHates (as defined in Section 2-32-45S(b) ef the Munk;ipal Cede) is a furedatory leader within the meaaing of Chapter 2-32 of the Mimicipal Cede, explain here (attach additioaal pages if accessary):

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 er in the name ofany other person or entity in the Matter?

[JYes ^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. Ualess sold pursuaat to a process of competitive l»dding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or m the aame of any other person or entity in the purchase ofany property that (i) belongs to the City, or (ii) is soid for taxes er 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 Saie?

[ ] 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 Busiaess Address Nature of laterest

4. The Disclosiag Party furtfier certifies that no prohibited financial interest in the Matter will be acquired by any Cky offkiat er employee.

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either 1. or 2. below. If the Disctosing Party checks 2., the Disclosing Party must disclose beiow or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

compty with these disclosure requirements may make any confract entered into with the City in connection with the Matter voidable by the City.

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

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

SECTION VI - CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

1. List below the names of ail persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbyiag contacts on behalf of the Disclosing Party with respect to the Matter: (Add stieets if accessary):

(If ao explanation appears or begias on tbe lines above, or ifthe letters "NA" or if the word "None" appear, it will be conclusivety presumed tbat the Disclosiag Party means tbat NO persons or entities registered under the Lobbying Disclosure Act ef 1995 have made lobbyiag contacts on behalf ofthe Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent ami witt not expend aay federally appropriated fuads to pay any persoa or eatity tisted in Paragraph A.l . above fbr his er her lobbytag activities or te pay any person or entity to influeace or attempt te influeace an officer or employee of aay agency, as defined by applicable federal taw, a member of Congress, an officer or employee ef Congress, or aa employee of a member of Coogress, ia connectioa with the award of aay federally fuaded coatract, making any federally funded grant or ioaa, entering into aay cooperative agreement, er to extend, coatiatte, reaew, amend, or modify aay 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 Intemal 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 Disciosing Party must obtain certifications equal in form and substance to paragraphs A.l. through A.4. above from aU subconfractors before it awards any subcontract and the Disclosing Party must maintain all such subconfractors' certificatioas for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

1. Have you developed aad do you have oa file affirmative action programs pursuant to applicable federai regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] Ne

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federai Confract Compliance Programs, or the Equal Employment Opportunity Commissioa aH reports due under the applicable fiHng requirements?

[ ] Yes [ ] No

3. Have you participated in aay previous confracts or subconfracts subject to the equal opportunity clause?

[JYes [JNo

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

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disciosures, and aclcnowiedgments contained in this EDS wiH become part of any confract or other agreement between the AppHcant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking ether action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinanees, Chapters 2-156 and 2-164 of the Munietpat Code, impose certain duties and obHgatieas oa persons or entities seeking City confracts, work, business, or transactions. The full text of these ordinances and a fraining program is available on tine at www .city ofchicago, org/Ethics, aad may also be obtained from the City s Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60619, (312) 744-9660. The Disclosiag Party must comply fully with the appHeable ordiQances.

C. If the City detennines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreemeat ia connectioa with which it is submitted may be rescinded or be void or voidable, aad the City may pursue aay remedies under the coafract or agreement (if aot rescinded or void), at l»w, er in equity, including terminating the Disctosing Party's participattoa in the Matter and/or declining to allow the Disclosiag Party to participate in other traasacttons 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 tfiis document available to the public oa its lateraet site and/or upon request. Some or att ofthe iaformatioa provided oa this EDS and aay attachments to tbis EDS may be made available to the public oa the Intemet, in respoase to a Freedom of Information Act request, er otherwise. By completiag and stgniag this EDS, ^ Disclosing Party waives aad releases aay possible rights or etakas which it may have agaiast the City in coanectiea with the piri>Iic release ef iaformatioa contained ia tbis EDS and also authorizes the City to verify tfie accuracy of aay iaformation submitted in this EDS.

E. The iaformatioa provided m this EDS must be kept curreat. Ia the event of changes, the Disclosing Party must st^leaaeat EDS up to the time the City takes action oa tfie Matter. If the Matter is a confract being baadted by the City's Department of Procurement Services, the Disclosing Party must update this EDS as tfte emtfraet requires. NOTE: With respect to Matters subject to Article I of Chs^ter 1-23 ofthe Mimical Cede (toiposing PERMANENT INELIGIBILITY for certaia specified offenses), the informatiea provided herein regarding el^ibiitty mu^ be kept ctarreat for a toager period, as required by Chapter 1-23 aad Section 2-154-026 ef ^e Municipal Cede.

The Disclosing P^y represents aad warrants tbat:

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 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.

C E R T I F I C A T I O N

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.

(Print or type rty)^-'

(Sign here)

(Print or type name of person signing)

.__.|/^.^i*vker (Print or type title of person signing)

Signed and sworn to before me on (date) at CM>:li-- Coxxxi\y.r^_

Commission ei<pires:

(state).

Notary Public.

I

Page 12 of 13

_qmGw.sBM ROBERT D6CQLER

NOTARY PUBUC - STATi OF UJNOiS MY COMMKiStON EXPtRES:06ai/17

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appeadix is to be completed oaly by (a) the AppUcaat, aad (b) aay legal entity which has a direct owaership iaterest in the AppUcaat exceeding 73 percent It is not to be completed by any legal eatity which has onfy an indirect owaership iaterest ia the AppUcant.

Under Municipal Code Sectim 2-154-015, the Disclosing Party must disclose whether such Disclosiag Party or aay "Applicable Party" or any Spouse or Dc»nestic Partner thereof cunently has a "famHial relationship" with aay elected eity official or department head. A "famiHal relatioaship" exists if, as of tfie date this EDS is sigaed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner tfiereof is related to the mayor, aay alderman, the city clerk, the city treasurer or aay city department head as spouse or dcmiestic partner or as aay ofthe following, wheth^ by blood or adoptioa: parent, child, brother er sister, aunt m uncle, niece or nephew, graadparem, grandchild, father-in-law, mother-in-law, s<m-ta-law, dau ter-irt-taw, stepfather or stepmother, stepsoa or stepdaughter, stepbrother or stepsister or hatf-brother or half-sister.

"AppHcable Party" means (1) aH executive officers ofthe EHsctosing Party Hsted ia Se^tm II.B.La., ifthe Disctosing Party is a cecporatioa; all partners ofthe Disclosing Party, tfie Enclosing Party is a general partner iip; att general partners and Hmited partners < the f sctosiag Party, if tfie Diseh)stng Party is a limited partoership; all managers, managiag members and members of the Disctosing Party, ifthe Disclosing Party is a limited Hability company; (2) all principal officers of the EHsclosiag Party; and (3) any person tiaviag more than a 7.5 percent ownership interest in the Disclosing Party. "Principal oSBcers" means the presii^t, chief operating officer, executive director, chief finsmcial oflicer, treasurer or secret^ of a legal eatity or aay person exercising similar authority.

Does the EHsclosiag Party or aay "Af licable Party" or aay Spouse or Dmnestic Partner therettf curreatly have a "famiHal relationst>q>" witfi aa elected city official or dep lmeat iiead?

[JYes 'No

Ifyes, please identify below (1) the same and title of such person, (2) tbe name ofthe legal eatity to which such persoa is coimected; (3) the aame and title of the elected city official or departmeirt head to whom such person lias a famiHal reiatioaship, and (4) the precise aature of such famiHal reiatioasfc .

Page 13 of 13

City of Chicago

Office of the City Clerk

Document Tracking Sheet

Or2013-637

Meeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

10/16/2013

Colon (35)

Order

Landmark fee waiver for property at 2760 N Milwaukee Ave

Committee on Zoning, Landmarks and Building Standards

ORDER

WHEREAS, Section 2-120-815 of the Municipal Code provides that the Chicago City Council may by passage of an appropriate order waive any fees charged by the City for any permit for which approval of the Commission on Chicago Landmarks (the "Commission") is required, in accordance with chapter 2-120 of the Municipal Code; and

WHEREAS, the permits identified below require Commission approval, in accordance with Section 2-120-740 of the Municipal Code; now, therefore,

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

SECTION 1. The foregoing recitals are hereby adopted as the findings of the City Council.

SECTION 2. The Commissioner of the Department of Buildings, the Commissioners of the Departments of Environment and Fire, the Director of the Department of Revenue, and the Zoning Administrator are hereby directed to issue those permits for which approval of the Commission on Chicago Landmarks is required pursuant to Chapter 2-120 of the Municipal Code free of charge, notwithstanding any other ordinances of the City Council to the contrary, for the property at:

Address: District/Building:

for work generally described as:

2760 North Milwaukee Avenue ("Property") Milwaukee-Diversey-Kimball District

Rehabilitation and 3' '' floor addition to an existing 2-story building, to include ground level commercial retail and upper level residential space.

Owner: Owner's Address: City, State, Zip:

Fox Chicago, LLC 1110 Pleasant Street Oak Park, Illinois 60302

SECTION 3. The fee waiver authorized by this Order shall be effective from October 1, 2013 through October 1, 2015, and shall not apply to additional developer service fees, stop-work order fees or any fines.

SECTION 4. That the permit purchaser for the Property shall be entitled to a refund of city fees for which it has paid and which are exempt pursuant to Section 1 hereof.

SECTION 5. This order shall be i an^ effect upon its passage.

NOTE: This is NOT a permit nor does it constitute a Letter of Approval for the above described work. A permit application for the work must be approved by the appropriate City department(s) as well as the Commission on Chicago Landmarks for this permit fee waiver, subject to City Council approval, to be valid.

C I T Y OF C H I C A G O 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/ i f applicable:

FgK

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. ^ t h e 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 I I .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: i P I ^ ^ O . A ' f '

C. Telephone: ~7^lg j^'l^'Qr^D Fax: -20^-^1^-9$^^^ Email: f^x <g3 (^>c^^

D. Name of contact person: P^\^ Y^'iC

E. Federal Employer Identification No. (if you have one): " ^ ' . . - I

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

G. Which City agency or department is requesting this EDS? l 'gAurravj ^C Q X riyai<»^S

*• U . ^ : . . U . A \ U . . . 4 - . . 1 P \ . . 4 . . . . . . A . . . 4- 0 . . n . . . . . . . n . . . . . A » 4 - C A . . . r ^ ^ n o If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

ver. 01-01-12 Page 1 of 13

S E C T I O N II -- D I S C L O S U R E OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person Limited liability company Publicly registered business corporation [ ] Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ ] Not-for-profit corporation General pai^tnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ ] Yes [ ] No Trust [ ] Other (please specify)

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

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 j[ "jNo [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf

Name/^ r \ \ /n A ^'^^^ /

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

Page 2 of 13

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

Name Business Address Percentage Interest in the

D n r-^ n A - / Disclosing Parly

S E C T I O N III - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S

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

[ ] Yes ^ N o

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

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature 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.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party Fees (indicate whether (subcontractor, attorney, paid or estimated.) NOTE: lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets i f necessary)

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

S E C T I O N V - C E R T I F I C A T I O N S

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[JYes [ ] N o

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 compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;

b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

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

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

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

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not 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: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Governmental Ethics) of the Municipal Code.

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

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 12-month 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").

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.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [wfiTnot

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

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

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? .

[ ] Yes X N O

NOTE: I f 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?

[ ] Yes [ ] No

3. I f 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 wil l 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.

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 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 MATTERS

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VI 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):

(I f no explanation appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it wil l 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 m paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

I f "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

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

Page 10 of 13

SECTION V I I - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

C. 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 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that:

Page I I of 13

F.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 of the items in F. 1., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

C E R T l F i C A T i O N

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.

(Sign here)

.^.r^tj».^._i^.\^.-(Print or type name of person signing)

jyi£.ckcr_ (Print or type title of person signing)

Signed a«d sworn to before me onj ^date) at C^3/<-' County

Commission expires:

Notary Public.

Page i 2 of 13

OFFICIAL SEAL ROeeRfTDBiEGLER

NOTARY PUBUC - STATE OF IU.IN01S MV COMMtSSION EXP1RES.0W1/17

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial relationship" with any elected city official or department head. A "familial relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section H.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, i f 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?

[ ] Yes JP>CNO

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

SECTION I - GENERAL INFORMATION

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

Check ONE ef the following three boxes:

Indicate whether the Diselosing Party submitting this EDS is: 1. [ ] the Applicant

V OR 2. a legal entity holding a direct or indirect mterest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: CZ^K'tCO-CAQ L,^ 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 ofthe Disclosing Party: \ \ \ 0 /^lgngQ/t-~f S>~f~

C. Telephone:^<g^ ^ ^ g - F a x : ~^0%-^^9'^Email: ^^<^ f^G>^. co^

D. Name of contact person: (^\, K V C J-Q

E. Federal Employer Identification No. (if you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

TVrr^^-^ Pee (Jan^gr i-^^^Aje^ ^^AD:^ <^ £>0 A)

G. Which City agency or department is requesting this EDS?"\)g/^n7>^eA^ e'^ \M><x.U/v°\ g /}J?

If the Matter is a contract being handled by the City s Depanment of Procurement Services, please complete the followmg:

SpeeHicatton # and Contract #

Ver.»i-«i.i2 Page 1 of 13

SECTION n - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the EHsclosing Party: [ ] Person [ ] Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership ^ Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a SO 1(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

2. For legal entities, the state (or foreign country) of incorporation or orgaai2ation, if applicable:

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

[]Yes [JNo [JN/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profh corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or o&er simitar entities, list below the legal tttIehotder(s).

If the eatky is a general partaership, United partnership, Kmited lia^ity company, tta»ted Uability partnership or joint ventwe, Kst b^w the name and tkle of each general partner, raaaaging memher, manager or any other person or entity &at controls the day-to-day management of the E>isclosing Party. NOTE: Each legal entity listed below must stthmk aa EDS oa ks own behaM*.

Name

2. Please provide the foHowtng information concerning each person or entity having a direct or indkeet benefietal interest (fscht^g ownership) in excess of 7.5% of Ae Diselosing Party. Examples of sueh aa mterest include shares in a coloration, partnership mterest ki a partsersbtp or joint venture.

Page 2 of 13

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

Name Business Address Percentage Interest in the -y\ { / t— n X>isclosing Party

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

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

[ J Yes ^ N o

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party nwst disclose the name and business address of eaeh subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Dbclosiag 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 Pmly is txH retired to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or e n ^ who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (I) a not-for-profit entity, oa an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as aa employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertain whether a disclosure is required under rttis Section, tiie Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t b.d." is

not an acceptable response.

{Ada sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes H^o [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[]Yes []No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipfd Code Chapter 1-23, Article I ("Article l"Xwhich the Applicaot should coasuH for defined terms (e.g., "doing business") and legal requkemeats), if the Disctosiag Party sttbmtttisg this EDS is &e Applieaat and is doing business with the City, then the Disclosiag Party certifies as follows: (i) neither the A^ttcant nor any coatrelliag person is cinrentty indicted or charged with, or has admitted guih of, or has ever been convicted of, or placed under sapervisien for, any criminal offense invcrfving actual, attempted, or conspiracy to c(M»mH ttfibery, theft, fraud, forgery, peijttry, dishonesty or deeeU against aa oilieer or en yloyee of iSbs City or any sister agescy; aad (u) the A^ieant understaads aad acknowledges that eompliaace with Articte I is a costtauiag requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent cmnpliance timeframe in Article I supersedes seme five-year compliance timeftames m 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 firom 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 defauh; and

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

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: e&atroh the

Disclosing Party, is cmitrcrfled by the Disclosing Party, or is, with the Disclosing Party, uader common control of another person or entity. Indicia of control include, without limttjrtion: interlockmg management or ownership; identity of interests among family members, shared facilities and equqimeat; common use of en^loyees; or organization of a buskaess entity fottowiag 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 terra Affiliated Entity means a person or eatity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other oflflcial, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to die direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

c. made an admission of such eoaduct 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 2-92-616 (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 widi 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 simitar 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. Neithi^ the Disclosing Party nor any Affitiated Entity is listed oa aay of the foltowiag lists maiatamed by the Office of Foreign Assets Conteot of the U.S. Department of die Treasury or the Bureau of Industry and Security of the U.S. Depar^nent of Comiii^ce or thek successors: die Specially Designated Nationals List, the Denied Perscms List, the Uav^fied List, ^e Eatky List aad the Debarred List.

6. The Disclosing Party understands and shall comply with the a^lkabk requirements of Chapters 2-55 (Legislative la^cter Geaeial), 2-56 (Inspector Geaeral) aad 2-156 (Governmental Ethics) &S the Muaic^t Cede.

7. If the Disclosiag Party is uaable to certify to any of the above statements in this Vtai B (Further CertifkattoHs), the Disclosing Party must exptaie below:

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 12-month 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").

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.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is y^not

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

2. If die Disclosing Party IS a financial institution, then the Disctosiag 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, aad none of them wiH 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 resuh in the loss of the privilege of doing business with the City."

If the Disclosiag Party is unable to make this pledge because it or aay 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):

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the tines 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 b^No

NOTE: I f you cheeked "Yes" to Item D. l . , proceed to Items D.2. aad D.3. I f you checked "No" to Item D. 1., proceed to Piul E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shaH 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 [ ] No

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

Please check either I . or 2. below. I f tiie Diselosing Party checks 2., the Disclosing Party must disclose below or in aa attaetunent to s 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 coxmccp<m with the Matter voidable by the City.

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

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

SECTION VI ~ CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

(If no explaaation appears CHT begins oa 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 Lobbyiag 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 aay 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, aa officer or employee of Coagress, 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, enteriag 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 alt such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to 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 Coatract Compliance Programs, or the Equal Emptoymeat Of^rtuntty Commission aH reports due WKter the a^Hcable filing reqakeme^s?

El Yes [INo

3. Have you partic^ted ki aay previous contracts or subcoafracts subject to the equal opportunity clause?

[JYes []No

If you cheeked "No" to questioa 1. or 2. above, please provide aa exptaafttion:

Page 10 of 13

SECTION V I I - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLL4NCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and aclcnowtedgments 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.cityofchicagQ.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 t>e 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 odierwise. By completiag aad sigaing this EDS, the Disclosiag Party waives aad releases aay possible rights or claims which it may have against the City in conaection with the public release of iaformation contained m this EDS and also authorizes the City to verify the accuracy of any iafoiination 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 Munic^al Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the iaformation provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 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. 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 of the date furnished to the City.

(Print or type name of Dj

(Sign here)

....../D-j cc.i?_<5Le/_.i j

(Print or type name of person signing)

(Print or type title of person signing)

SignecLajid sworn to before me on (date) at . . . ._C^/S_ County, (statey.

Commission

Notary Public.

Page 12 of 13

ROeSITOafiGLER NOTARY nOUC • STATE OF lUMQIS MY COMMSSiON E)(P>IES.-0iai/t7

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVrT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership uoterest in the Applicant exceediag 7.5 perceat It is aot to be completed by aay l^al eatity which has only an indirect ownership iaterest in the Applicant

Under Municif>al Code Secticm 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" widi any elects city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or aay "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 adc^on: parent, child, brother or sister, aunt or uncle, niece or n^tiew, gran^arent, grandchild, &dier-in-law, mottier-in-law, son-in-law, daughter-to-law, stepfi ier or stepmother, stepson or stepdau ter, stepbrother or stqisister or half-brother or half-sister.

"A^licable Party" means (1) aU executive officers of the Disclosing Party listed in Section EB. 1 .a., if the Disclosing Faxty is a corporation; all partners of the Disclosing Party, if the Disclosiag Party is a general partnership; aH general partners and limited partners of the Disclosing ?arty, if &e Disclosing Party is a limited pjutnership; all managers, managing members and members ofthe Disclosing Party, if the EHsclosing Party is a limited liability company; (2) all principal office of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership intoest in the Disclosmg Party. "PrincqTal 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 Pasty or any "Apptiakie Party" or any Spouse or Domestic Partner thereof currently have a "familial relati(»iship" with m elecjted city official or department head?

C JYes

If yes, please identify below {l)tbe name and title of such persoa, (2) the aarae ofthe legal eatity to which such person is coimected; (3) the name and title of the elected city official or departmeirt head to whom such person has a familial relationship, and (4) the precise nature of such fiimilial relationship.

Page 13 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE ofthe following three boxes:

Indicate whether the Disclosing Party su^ittiag this EDS is: 1. [ } the Applieaat

OR 2. [ } a legal entity bol^ag a direct or iadtiect iaterest in the Applieaat. State the legal aame of the

Appticaat in which die Diselosiag Party holds an interest: OR

3. 1^ a legal entity with a right of control (see Section 1I.B.1.) State die legal name ofthe entity in which the Disclosing Party holds a right of control: F~0X- C Jn.'ier nt.' Ci L c _

B. Business ad^ess ofthe Disclosing Party: PijPdScjf^Jlr C / -

C. TelephQne?lS>^ Fax: 7^M-9CS-V Email: /n:V^.,iC^ r/ C)c

D. Name of ceatact person:

E. Federal En^toyer Identifieatten No. (if you have oae): _ ^ - 'f-^-.

F. Brief desertion »f contract, ^Bsacti<» or other uad^aking (referred to below as the "Matter") to which (his EDS pertains. (lachide project number aad locatioa of pve ofty, if applicable):

G. Which City agency or department is requestmg iWs EDS77)g<'<VTy»eAr v rrOaS/A^

If the Matter is a eoatract being handled by die City's Department of PyoctHremettt Services, please

Specifieatioa # and Contract #

Ver.9i4i-» Page I of 13

SECTION n - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

I. Indicate the nature of the Disclosing Party: ^ J. Person ^ Limited liability company [ ] Publicly registered business corporation [ ] Limited liability partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501 (cX3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

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

3^UvAOl £

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 (1 N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other simitar entities, list below the legal tttleholder(s).

If the entity is a general partnership, limited partnersbqi, limited liability eorapaay, limited liability partnership or joi^ venture, Hst below the aame aad title of each geaeral partner, maaagiag member, manager or any ether person or entity that controls the day-to-day maaagemeat of the Disclosiag Party. NOTE: Each legal entity listed below must submit aa EDS oa its owa behalf

Name i Title .

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other simitar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage Interest in the n Disclosing Party

SECTION HI - BUSINESS RELATIONSHIPS WITH C I T Y ELECTED OFFICIALS

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

[]Yes yi No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disctosiag Party must disclose the name and business address of each subccm^actor, attorney, lobbyist, acceuataat, eonsahaat and aay other persoa or eatity whom the Disctosiag Party has retaiaed or expects to retaia ia coaaectioa with the Matt^, as welt as the aatwe ofthe retatioash , aad tt^ total amouat of ^ fees paid or estaaated to be paid. The Diselosiag Party is not requared to disclose employees who are paid solely through the Disclosmg Party's regular payroll.

"Lobbyist" meaas aay persoa or entity who undertakes to iaHuence aay tegislative or atfaniaistrative actioa oa behalf of aay persoa or entity other ^ n : (1) a aot-for-profk e a ^ , on aa uapaid basis, or (2) h^self. "Lobbyist" also meaas aay persoa or entity aay part ef whose duties as aa employee of another iacludes undertaking to iafluence aay legislative or admiatstrative action.

If the Disclosing Party is uacertaia whether a dodosure is requ^ed under ftis Sectioa, the Disclosiag Party must either ask the City whether disclosure is reqtiked or aiake Ae dtsctosure.

Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained)

Relationship to Disclosing Party (subcontractor, attorney, lobbyist, etc.)

Fees (indicate whether paid or estimated.) NOTE: "hourly rate" or "tb.d." is not an acceptable response.

(Add sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[] Yes jiNo f JNO person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ ] Yes [ ] No

B. FURTHER CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article P'Xwhich the Applicant should consult for defined terms (e.g., "doing business") aad legal requirements), if the Disclosiag Party submitting this EDS is the Applieaat aad is doiag business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlHag person is currently indicted or charged with, or has admitted guih of, or has ever beea convicted of, or placed under supervision for, any criminal offense involviag actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against aa officer or employee ofthe City or aay sister agency; and (ii) the Applicant understands and acknowledges that eompliaace with Article I is a eoatiaumg requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permaaent 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 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 ctause B.2.b. of this Seetica V;

d. have not, within a five-year period preceding the date ef this EDS, had oae or more pfd>Hc transactions (federal, state or toeal) termiaated for cause or default; and

e. have not, within a five-year period prece^g the date of this EDS, beea eoavicted, a^dged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceraing environmental violations, instituted by the City or by the federal government, any state, or y other unit of local government.

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

• the Disclosing Party; • any "Contractor" (meaaing any eoa raetfx or sidieoatractor used by Disctosiag Party m

coaaectioa with the Matter, including but net limited to aU persoas or legal eatities disclosed under Section IV, "Disclosure of Subccmtractors and Other Retained Parties"); • aay "AffUiated Eatity" (meaatag a p^ea or eatity that, dh ectly or iadkectly: consols ^

Diselosifig Party, is coab'olled by the Disclosiag Party, or is, with Diselosiag Party, uader common control of aaother perscm or eat^. ladkia of c o n ^ mchide, without limit^iea: inteiiocktag management or owaersltip; kfeatity of interests among famify meabers, sh»ed facilities and eqaq^aent; eonuaoa use of emptoyeea; er orgaaizrttea of a busmess e s ^ foHowkig tfte iB€4ig^ity of a busiaess eatity to do tmstsess with federal or state or local geverameat, mctudiAg the City, using substaatiany the same maaagemeat, ownership, er f^ae^ats as the iaelig^te eatity); with resect to Coatraetors, the term AHIHated E a t ^ meaas a persoa or entity that dtreetly er iadirectly controls the Coatracter, is eo 'oHed by it, or, with die Coatractor, is under eomttea coatrol ef aaother persoa or eatity; • aay respoasible eflleial ef the Diselosiag Party, aay Coatractor or aay Afi^ated Eatity or aay

other official, ageat or employee ef ^ Diselesiag Party, aay Co^actw er aay AffHt^ed Entity, acting pursuant to the cfoeetioa &t authorization of a responsible officiai of the Disctosiag Party, any Contractor or aay Affiliated Eatity (c Hteetively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

c. made aa admission of such conduct described ia 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 aay 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 ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security of the U.S. Departaaent of Commerce or their successors: the Specially Designated Nationals List, the Denied Persoas List, the Unverified List, the Eatity List aad the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector Geaeral), 2-56 (Inspector General) aad 2-156 (Goverameatat Ethics) ofthe Muakipal 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:

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 12-month 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").

9. To the best ofthe Diselosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Diselosing Party has given or caused to be given, at any time during the 12-moath period preceding the execution date of this EDS, to an eaiptoyee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generaHy availabte to City ea^toyees or to the general public, or (ii) food or drink provided in the course of official City business aad having a retail value of less thaa S20 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.

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies tbat the Disclosing Party (check one)

[ ] is ^^snoi

a "fiaaacial iastitvtion" as defined in Sectioa 2-32-455<b) of the Municipal Code.

2. If Ae Disclosmg Party IS a fiaaacial iastittttioB, thea the Disclosing Party pledges:

"We are not aad wtti not become a predatory leader as defined ia Chapter 2-32 of the Municqial Code. We f HTtter pie^e that acme of oar affiliates is, and aoae of them wiH become, a ^datory tender as de^ed ia Chi^er 2-32 of the Municipal Code. We uaderstaad ftat becomiag a ^edatory leader er beeomtag aa affiliate of a predatory leader may result m the loss of the privilege of doiag bttsiaess with Cky."

if ttie Diselosiag Party is usable to make this pledge because it or amy ef its affiKi^s (as defined in Sectkia 2*32-455(b) ofthe Muaieipal C e ^ ) is a predatory leader withia the meaaiag of Chapter 2-32 of the Muaie^l Code, explata here (attach addittoaal pages if aecessaty):

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 ^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 pennitted, 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 emiaeat 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 aad business addresses of the City officials or employees having such interest and identify the nature ef such iaterest:

Name Busiaess Address Nature of Interest

4. The Disclosing Party further certifies that ao prohibited financial iaterest ia the Matter wilt 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 alt 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.

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

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

SECTION VI ~ CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

I. List below the names of alt persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disctosiag Party with respect to the Matter: (Add sheets if necessary):

(If ao explanation appe»s or begins on the lines above, or if the letters "NA" or if ^ word "None" appear, it will be coaclusively Resumed that the Disclosiag Party meaas that NO persoas or entities registered uader the Lobbyiag Disclosure Act of 1995 have made lobbymg coatacts oa behalf of the DisclostBg Party with respect to the Matter.)

2. The Disclosing Party has aot speat aad will aot expead aay federally apj n^riated faads to pay aay persoa or entity listed in Paragraph A. 1. above for his or her lobbyiag activkies or te pay aay persoa or eatity to iaflueace er attem^ to mfiueace aa officer or enifi eyee of aay agency, as defiaed by af^lieable federal law, a memb^ of Coagress, aa officer or employee of Coagress, er aa ea iloyee of a member of Coagress, ia coaaectioa with the award of aay federalty funded eoatract, making aay federaHy funded grant or loan, eatering iato aay cooperative agreemeftt, or to extend, coatieue, reaew, amend, or modify aay feden^ fttaded cofHraet, graat, toaa, er cooperative agreemeat.

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.I. through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [ ] No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ 3 No

2. Have you filed with the Joiat Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ 3 Yes [ ] No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity ctause?

[ ] Yes [ ] No

If you checked "No" to questioa 1. or 2. above, please provide aa explaaation:

Page 10 of 13

SECTION VII ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLLANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees tbat:

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, woik, busaiess, or transacti<ms. The full text of these ordtaaaces aad a training program is available on line at www.eit¥Qfchicaeo.oig/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Cbieago, IL 60610, (312) 744-9660. The Disclosing Party must compty fully with the applicable ordinances.

C. If the City determines that any information provided m this EDS is false, incomplete or inaccurate, any contract or ether agreement in connection with which it is submitted may be rescuided or be void or voidable, and the City may pursue any remedies uader the eoatract or agreemeat (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter aad/or deciiaing 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 te midte this document available to the public oa its internet site and/or i ^ n request. Some or all of the information provided on is EDS and aay attachmeats to this EDS may be made available te the public oa the lateraet, ia response to a Freedom of lafermatioa Act request, or otherwise. By completiag a»d sigaiag this EDS, the Disctosiag Party waives aad releases aay possible rights or ctakfts which it may have against the City ia coimection with the public release of iBformaUoa ceatamed ia this EDS aad also authorizes the City to verify the acciaraey of any iafomatioa submitted ia this EDS.

E. The iafermatioa provided ia this EDS must be kept eurreat. Ia the event of changes, the Disclosing Puty must sapptemeat this EDS ^ to ^e time the City takes action oa &e M a ^ . If the Matter is a coateaet beiag haadled by the City's Department ef Procureaieat Services, the Disetosmg Party must update this EDS as the c e ^ ^ requaes. NOTE: Wiih reject to Matters subject to Arttcle I of Ch^er 1-23 ofthe Muak^al Code (imposing PERMANENT INELIGIBILITY fbr certain specified offenses), the iaforaAatioB provided hereia regctfdiag eHgtbttity mast be kept eurreat fbr a loager period, as required by Ch^ter 1-23 aad Secttoa 2-154-020 ofthe Mwiteipal Co^.

The Disctosiag Party represeats aad warraats 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 [ 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.

(Print or typ< artyy^ •J- LLC

(Sign here)

J^.C'\^JQJ3|2 .^Q^k. (Print or type name of person signing)

j / ^ i ^ i ^ e r . -(Print or type title of person signing)

Signed and sworn to before me on (date) at C ^ . l ^ County,'--;/^ . - ^ ^ . (state).

Commission e<pires:

Notary Public.

Page 12 of 13

ROBERT DBEGIER NOTARY PUBUC • STATE OF ILMQtS MY COMMISSION EXPAE$:08/21/17

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFTDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

This Appeadix is to be completed oaly by (a) the Applieaat, aad (b) aay legal eatity which has a direct owaership iaterest ia the Applieaat exceediag 7.5 perceat It is aot to be coaqileted by any legal eatity which has oaly aa ladirect owaership interest ia the Applieaat

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whetho* such Disetosing Party or aay "A^licabte Party" or any Spouse or Domestic Partner thereof currently has a "faaali^ felatioaship" with any elected city official or departm«t head. A "familial relaticmship" exists if as of Ae dale this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner &»eef is related to the mayor, any alderman, Ihe city clerk, the city treasurer or aay city department head as ^ouse or domestie partner or as any of the fotlowmg, whether by blood or adoption: parent, child, brodier or ssier, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, scm-in-taw, daughto ia-taw, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or hatf-brether or tudf-sister.

"Applkable Party" means (1) all executive officers of the Disclosing Party listed in Sec^a II.B.l.a., if the Diselosing Party is a corporation; all partners ofthe Disetosing Party, if the Disclosing P«ty is a general partnership; all general partners and limited partners of die Disctosiag Party, if the Disclos^ Party is a limited partnership; alt managers, managing members and memt>ers 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 ownerstiip interest ia the Disclosing Party. "Principal officers" means the presid^^ chkf operating office, executive directs, chief financial officer, treasurer or secretary of a legal eatky or any person exercising similar authority.

Does the Disetosing Party or aay "Applicable Party" or aay Spouse or Domestk PartBer di»eof curre ly have a "fmnilial relattonship" with an dected city official or (fepartoient head?

[JYes j ^ l 'No

If yes, please identify below (1) Ac aame and title of such person, (2) the nsaae of the legal oitity to which such person is connected; (3) die name and titte of the elected city official or 4epaetsBettt heai to whom such person has a familial relattoashqp, and (4) the precise aature of such famiK^ relati(»ship.

Page 13 of 13

City of Chicago

Office of the City Clerk

Document Tracking Sheet

O2013-7598

Meeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

10/16/2013

Beale (9)

Ordinance

Approval of plat of Pullman Park Phase 2 subdivision

Committee on Transportation and Public Way

SUBDIVISION ORDINANCE "y

Be it Ordained by the City Council of ttie City of Chicago:

SECTION 1. Chicago Department of Transportation, the Commissioner or the designee of the Commissioner, are hereby authorized and directed to approve a proposed subdivision Pullman Park Phase 2 being a subdivision bounded by E. 107" Street, S. Doty Avenue, E. 111'^ Street, and the Chicago, Rock Island & Pacific Railroad (approximately S. Langley Avenue) and legally described in the attached plat (Exhibit A, CDOT File: 14-09-13-3624) which, for greater clarity, is hereby made a part of this ordinance.

SECTION 2. The subdivision herein provided for is made upon the express condition that within one hundred eighty (180) days after the passage of this ordinance, the applicant shall file or cause to be filed for record in the Office of the Recorder of Deeds of Cook County, Illinois a certified copy of this ordinance, together with the attached Plat approved by the Department of Transportation's Superintendent of Maps and Plats

SECTION 3. This ordinance and exhibit subdivision plat shall take effect and be in force from and after its recording.

Honoraljie Anthony Beale Alderman, 9th Ward

EXHIBIT "A"

LOCATICW KW

PLAT OF SUBDIVISION

PULLMAN PARK - PHASE 2 BEING A SUBDIVISION OF PART Of THE SOUTHWEST OUARTEB OF SECTIDN H AM) THE

SOUTHEAST OUARTER OF SECTION 15. ALL IN TD»NSHIP 37 NORTH. RANGE M EAST OF THE THIRD PRINCIPAL UERIOIAN. IN COOK COUNTY. ILLINOIS. I

- N —

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L MJ. OJHOniWS BWGN WEOM MV MCASUCD IM-ESS NOTLO.

2. BASIS or BCAWHCII m c NCAIH BUCD <M ctotc i ic aSUVATICH L EAST IOC

CHICMO f lOBMOCO OtlTtAttnS lOaO C. UIFH ST1CCT. CMCUa, R. t o u t

* i JS PI '^SIOO SWJUI K ASSUCD BT S C J U tfASUIENUrS

CD0T«14-09-13-3624

F.IJL 25-14-30O-an PMTI : s - i s - iM-ou r M T i

7. TMS ajwiviSKH IS lusiD Ol » n v r i i x n Bcuo t f r smvEr pfCFWCD r o i nc L M C U tMcaviNC cmcASM[p rmccL. SMD SHAT MS rnETAMD iMXJt Joe na M I . L U T KVISEO SE^TEIAU 24. KXH MO * COPT Of KtlOt IS A*AILMU t r o t FCMST. BOUOMT M M C(»1.CTtD M l [xiSTinc wmMCxTAtiOM snom AS or UJACH, locn.

siprttacn 24. 2011.

% TtC mWDSm LAK) in t FCA LOT S 11 IMUITRIDL.

1 u i » 7 n

PLAT OF SUBDIVISION

PULLMAN PARK - PHASE 2 BEING A SUBDIVISION OF PART OF THE SOUTHKEST OUARTER OF SECTION H AND THE

SOUTHEAST OUARTER OF SECTION 15, ALL IN TOUNSHIP 37 NORTH, RANGE H EAST OF THE THIRO PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS.

PROPERTY DESCRIPTION:

A PARCEL OF LAND IN PARTS OF THE SOUTHWEST QUARTER OF SECTION 14 AND THE SOUTHEAST QUARTER OF SECTION 15. ALL IN TOWNSHIP 37 NORTH, RANGE H EAST OF THE THIRO PRINCIPAL MERIDIAN. IN COOK COUNTY, ILLINOIS. DESCRIBED AS FOLLOWS: COMMENCING AT THE POINT OF INTERSECTION OF THE EAST LINE OF THE SAID SOUTHEAST QUARTER OF SECTION 15. OR THE WEST LINE OF SAID WEST HALF OF SECTION M . WITH THE NORTH LINE OF EAST lUTH STREET (BEINC A LINE DRAWN PARALLEL WITH AND 50 FEET NORTH OF THE SOUTH LINE OF SAID SECTIONS 14 ANO 15); RUNNING THENCE WEST ALONG SAID NORTH LINE. A DISTANCE OF 365.73 FEET TO A POINT ON A CURVE 75.00 FEET EASTERLY ANO CONCENTRIC WITH THE EASTERLY LINE OF CHICAGO, ROCK ISLAND ANO PACIFIC RAILROAD RIGHT OF WAY 130 FEET WIDE. FORMERLY THE PULLMAN RAILROADli THENCE NORTHEASTERLY ALONG LINES 75.00 FEET EASTERLY AND CONCENTRIC OH PARALLa WITH SAID EASTERLY LINE FOR THE NEXT FOUR COURSES; (1) THENCE NORT)€ASTERLY 279.86 FEET. ALONG THE ARC OF A NON-TANGENT CIRCLE TO THE RIGHT, HAVING A RADIUS OF 626.50 FEET ANO WHOSE CHORD BEARS NORTH 29 DEGREES 20 MINUTES 17 SECONDS EAST, 277.54 FEET TO A POINT OF TANGENCY: (2) THENCE NORTH 42 DEGREES OS MINUTES 06 SECONDS EAST, 61.73 FEET TO A POINT OF CURVATURE: <3I THENCE NORTHEASTERLY 217.98 FEET. ALONG THE ARC OF A TANGENT CIRCLE TO THE LEFT. HAVING A RADIUS OF 1356.57 FEET AND WHOSE CHORD BEARS NORTH 37 DEGREES 31 MINUTES 54 SECONDS EAST. 217.75 FEET TO A POINT OF COMPOUND CURVATURE: (41 THENCE NORTHEASTERLY 66.59 FEET, ALONG THE ARC OF A TANGENT CIRCLE TO THE LEFT, HAVING A RADIUS OF 345.04 FEET AND WHOSE CHORD BEARS NORTH 27 DECREES 24 MINUTES 00 SECONDS EAST, 66.48 FEET TO THE POINT OF BEGINNING:

THENCE CONTINUING NORTHERLY 48.46 FEET, ALONG SAID CONCENTRIC ARC OF A TANGENT CIRaE TO THE LEFT, HAVING A RADIUS OF 345.04 FEET AND WHOSE CHORD BEARS NORTH 17 DEGREES 50 MINUTES 51 SECONDS EAST, 48.43 FEET TO A POINT OF TANGENCYi THENCE NORTH 13 DEGREES 49 MINUTES 25 SECONDS EAST. ALONG A LINE 75.00 FEET SOUTHEASTERLY OF ANO PARALLEL'WITH THE EASTERLY LINE OF CHICAGO, ROCK ISLAND ANO PACIFIC RAILROAD RIGHT OF WAY OO FEET WIDE, FORMERLY THE PULLMAN RAILROAD), 1688.44 FEET: THENCE SOUTH 68 DEGREES 24 MINUTES 59 SECONDS EAST, PERPENDICULAR WITH THE NORTHWESTERLY LINE OF PULLMAN PARK - PHASE 1 RECORDED JUNE 19. 2011 AS DOCUMENT 1120029049. A DISTANCE OF 818.71 FEET TO A POINT ON THE NORTHWEST LINE OF SAID PULLMAN PARK - PHASE 1: THENCE SOUTH 21 DEGREES 35 MINUTES 01 SECONDS WEST. ALONG SAID NORTHWEST LINE. 1021.00 FEET TO A BEND POINT: THENCE NORTH 68 DEGREES 24 MINUTES 59 SECONDS WEST, ALONG A NORTHERLY LINE OF LOT 4 IN SAID PULLMAN PARK - PHASE 1, A DISTANCE OF 360.98 FEET TO A CORNER THEREOF: THENCE WESTERLY 42.32 FEET. ALONG THE ARC OF A NON-TANGENT CIRaE TO THE RIGHT, HAVING A RADIUS OF 53.00 FEET AND WHOSE CHORD BEARS SOUTH TO DEGREES 10 MINUTES 43 SECONDS NEST, 41.21 FEET TO A POINT ON A NON-TANCENT LINE, SAID NON-TANGENT LINE ALSO BEING A WESTERLY LINE OF SAID LOT 4: THENCE SOUTH 22 DECREES 54 MINUTES 29 SECONDS WEST, ALONG SAID WESTERLY LINE, 596.09 FEET TO A POINT ON THE SOUTH LINE OF SAID LOT 4: THENCE SOUTH 88 DEGREES 36 MINUTES 34 SECONDS WEST. ALONG THE WESTERLY EXTENSION OF SAID SOUTH LINE. 197.58 FEET TO THE POINT OF BEGINNING, IN COOK COUNTY. ILLINOIS.

ACCESS EASEMENT DESCRIPTION:

A PARCEL OF LAND IN PARTS OF THE SOUTHWEST QUARTER Of SECTION 14 AND THE SOUTHEAST OUARTER OF SECTION 15. ALL IN TOWNSHIP 37 NORTH. RANGE 14 EAST OF THE THIRD PRINCIPAL MERIDIAN, IN COOK COUNTY, ILLINOIS, DESCRIBED AS FOLLOWS: COMMENCING AT THE POINT QF INTERSECTION OF TW EAST LINE OF THE SAID SOUTHEAST QUARTER OF SECTION 15, OR THE WEST LINE OF SAID WEST HALF OF SECTION 14. WITH THE NORTH LINE OF EAST UITH STREET (BEINC A LINE DRAWN PARALLEL WITH AND 50 FEET NORTH OF THE SOUTH LINE OF SAID SECTIONS 14 AND 151; RUNNING THENCE WEST ALONG SAID NORTH LINE. A DISTANCE OF 365.73 FEET TO A POINT ON A CURVE 75.00 FEET EASTERLY AND CONCENTRIC WITH THE EASTERLY LINE OF CHICAGO. ROCK ISLAND AMD PACIFIC RAILROAD RIGHT QF WAY 130 FEET WIDE, FORMERLY THE PULLMAN RAILROAD), SAID POINT ALSO BEING THE POINT OF BEGINNING; THENCE CONTINUING SOUTH 88 DEGREES 36 MINUTES 34 SECONDS WEST, ALONG SAID NORTH LINE. 72.15 FEET TO A POINT ON A CURVE 6.00 FEET EASTERLY AND CONCENTRIC WITH THE EASTERLY LINE OF CHICACO. ROCK ISLAND AND PACIFIC RAILROAD RIGHT OF WAY (30 FEET WIDE, FORMERLY THE PULLMAN RAILROADli THENCE NORTHEASTERLY ALONG LINES 6.00 FEET EASTERLY AND CONCENTRIC OR PARALLEL WITH SAID EASTERLY LINE FOR THE NEXT FIVE COURSES; (11 THENCE NORTHEASTERLY 332.90 FEET, ALONG THE ARC OF A NON-TANCENT CIRCLE TO THE RIGHT, HAVING A RADIUS QF 695.50 FEET AND WHOSE CHORD BEARS NORTH 28 DEGREES 25 MINUTES 23 SECONDS EAST, 329.73 FEET TO A POINT OF TANGENCY: (21 THENCE NORTH 42 DEGREES 08 MINUTES 06 SECONDS EAST, 6L73 FEET TO A POINT OF CURVATURE: (3> THENCE NORTHEASTERLY 206.89 FEET, ALONG THE ARC OF A TANGENT CIRCLE TO THE LEFT, HAVING A RADIUS QF 1287.57 FEET AND WHOSE CHORD BEARS NORTH 37 DECREES 31 MINUTES 54 SECONDS EAST. 206.67 FEET TO A POINT OF COMPOUND CURVATURE; (41 THENCE NORTHEASTERLY 92.04 FEET. ALONG THE ARC OF A TANGENT CIRaE TO THE LEFT. HAVING A RADIUS QF 276.04 FEET AND WHOSE CHORD BEARS NORTH 23 DEGREES 22 MINUTES 34 SECONDS EAST. 91.62 FEET TO A POINT OF TANGENCY; (51 THENCE NORTH 13 OEGREES 49 MINUTES 25 SECONDS EAST, 1697.85 FEET; THENCE SOUTH 68 DEGREES 24 MINUTES 59 SECONDS EAST, PERPENDICULAR WITH U S NORTHWESTERLY LINE OF PULLMAN PARK -PHASE 1 RECORDED JUNE 19, 2011 AS DOCUMENT 1120029049, A DISTANCE OF 69.64 FEET TO A POINT QN A LINE 75.00 FEET EASTERLY AND PARALLEL WITH THE EASTERLY LINE OF CHICAGO. ROCK ISLAND AND PACIFIC RAILROAD RIGHT OF WAY (30 FEET WIDE. FORMERLY THE PULLMAN RAILROAD): THENCE SOUTHWESTERLY ALONG LINES 75.00 FEET EASTERLY ANO CONCENTRIC QR PARALLEL WITH SAID EASTERLY LINE FOR THE NEXT FIVE COURSES; (11 THENCE SOUTH 13 DEGREES 49 MINUTES 25 SECONDS WEST, 1688.44 FEET TO A POINT OF CURVATURE; (21 THENCE SOUTHWESTERLY 115.05 FEET. ALONG THE ARC OF A TANGENT CIRCLE TO THE RIGHT, HAVING A RADIUS OF 345.04 FEET ANO WHOSE CHORD BEARS SOUTH 23 DEGREES 22 MINUTES 34 SECONDS WEST, 114.52 FEET TO A POINT OF COMPOUND CURVATURE: (3) THENCE SOUTHWESTERLY 217.98 FEET, ALONG THE ARC OF A TANGENT CIRCLE TO THE RIGHT, HAVING A RADIUS OF 1356.57 FEET ANO WHOSE CHORD BEARS SOUTH 37 OEGREES 31 MINUTES 54 SECONDS WEST. 217.75 FEET TO A POINT OF TANGENCY: (41 THENCE SOUTH 42 DEGREES 08 MINUTES 06 SECONDS WEST. 61.73 FEET TQ A POINT OF CURVATURE; (51 THENCE SOUTHWESTERLY 279.86 FEET, ALONG THE ARC OF A TANGENT CIRCLE TO THE LEFT, HAVING A RADIUS QF 626.50 FEET AND WHOSE CHORD BEARS SOUTH 29 DEGREES 20 MINUTES 17 SECONDS WEST, 277.54 FEET TO THE POINT OF BEGINNING. IN COOK COUNTY. ILLINOIS.

a , M J O S a a n , * w U n u u . a

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CDOT*^14-09-13-3624

C I T Y OF C H I C A G O ^ a i ^ g ^ ' W ^ ^ ^ ^ ^ i E C O N O M I C 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 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:

North Pullman 111th, Inc.

Check ONE ofthe foiiowing three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [X] 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 Csee Section n.B. 1 S t a t e the leeal name of the entitv in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 800 Nicollet Mall

Minneapolis, MN 55402

C. Telephone: 314-335-2560 Fax: 314-335-2568 Email: matthew.potter@usbank.com

D. Name of contact person: Matthew W. Potter

E. Federal Employer Identification No. ( i f you have one)

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Subdivision application for property generally located at 720 East 111th Street

G. Which City agency or department is requesting this EDS? Department of Housing and Economic Development

I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

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

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

[ ] Yes [ ] No ^ N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal tideholder(s).

I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

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

President

Senior Vice President

Senior Vice President

Secretary

Treasurer

Asst. Secretary

Asst. Secretary

Terrance R. Dolan

Jeffrey Shea

N P l l l OFFICERS

Terrance R. Dolan

Jeffrey Shea

John P. Kinsella

Laura F. Bednarski

Jeffrey Shea

Matthew B. Krush

Cara L. Seeley

N P l l l Directors

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

Name Business Address Percentage Interest in the ^ B<o<o Disclosing Party ^

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

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

• - r r, -TAvt- n r - s - r n ' t - cy^O- jC/fc-^^C-rJCicr^ [ ]Yes [~JNo • ' ••" •

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or esdmated.) NOTE: to be retained) lobbyist, etc.) "hourly rate

; '/o C/<<iO't'Dc- j-r , i •'/'TSS" not an accep

" or "t.b.d." is itable response. 7 f , 0 0 0

W . /)AOl}>Cr^ i ' ^ '^ t 33?c?0 ('o*'3l«-'<.r,j.^ iLo, ooo

(Add sheets if necessary) fF&^> Ar2(. C^^U^AT^UC^ [=0(1- pL,L.i/^4.^ -J/l4f-'ifofi..^/i-7^<}t'^ l^- ,

[ ] Check here if the Disclosing Party has not retained, nor expects to re'tain, any such pei c.iS or entities.

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ v f ^ p [ ] Yes No [vfNo person directly or indirectly owns 10% or more ofthe Disclosing Party.

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

[ ]Yes [ ] N o

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 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 . 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 govemment;

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; em.bezzlement; theft; forgery; bribery; falsification or destruction of records; m.aking false statements; or receiving stolen property;

c. are not presently indicted for, or criminally or civilly charged by, a govemmental 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

c. 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 hy the City or by the federal govemment, any state, or any other unit of local government.

3. The certifications in subparts 3, 4 and 5 concem: i

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly; controls the |

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity' following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); I with respect to Contractors, the term Affiliated Entity means a person or entity that direcdy or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, | acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affihated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal govemment or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or ofthe United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security 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 (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 Disciosine Party must explain below: ine J:'arty

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l 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 12-month period preceding the execution date ofthis EDS, an employee, or elected or appointed official, ofthe City of Chicago (if none, indicate with "N/A" or "none").

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 ofthis EDS, to an employee, or elected or appointed officia], 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

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is f^ isnot

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of them wil! 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 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):

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 REGARDE^IG 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^ -THt- 13^5^ C?f- 0\J^ /CAo^i-(^Oo

NOTE: I fyou 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?

[ ] Yes No

3. I fyou 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.

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 Part}' has found records of investm.ents or profits from, slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes ful l disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI -- CERTIFICATIONS FOR F E D E R A L L Y FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section V I I . For purposes ofthis 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 "N A" 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 i 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 wil l 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 Intemal Revenue Code of 1986; or (ii) it is an organizadon described in section 501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activides".

5. I f the Disclosing Party is the Applicant, the Disclosing Party m.ust 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 certificadons promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

I f 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? J^i^O£-0

,Yes [ ] N o

I f 'Ves , " answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ] Yes [ ] No

If you checked "No" to question ] . or 2. above, please provide an explanation:

Page 10 of 13

SECTION V I I - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, P E N A L T I E S , DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it m.ust 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 entides 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 i "vvith 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 Intemet, in response to a Freedom of Infomiation 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 dme 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 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 Usted by the U.S. E.P.A, on the federal Excluded Parties List System ("EPLS") maintained by the U . S. General Services Admirustration.

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 wil l not, widiout 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 ( i f 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 true, accurate and complete as of the date fumished to the City.

(Print or type name of Disclosing Party)

(Print or ty^^ame of person signing) | m m ^ ^ " f ^ K . r-. ^ V S S f MY COMMISSION

0 T . EXPIRES JAN. 31,2015 (Print or type title of person signing)

Signed and swom to before me on (date) MU/INJ

at l\AlV\nMpDli ^County, M l V ^ ^ ' ^ (^^^^^^

CT ^ Commission expires: V ^ \ ' 2 / ^ l ^

Notary PubUc.

Page 12 of 13

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the 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 tiiereof 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 "Apphcable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, fhe 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, 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 n.B.l.a., i f the Disclosing Party is a corporation; all partners of the Disclosing Party, i f the Disclosing Party is a general partoership; all general partners and hmited partners of the Disclosing Party, i f the Disclosing Party is a hmited partnership; all managers, managing members and members of the Disclosing Party, i f the Disclosing Party is a limited habihty 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 Partaer thereof currently have a "familial relationship" with an elected city official or department head?

[]Yes ^ N o /p-^^i^^ (Pt/t- ;>'G?.>-.j -r

If yes, please identify below (1) the name and title of such person, (2) fhe 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

(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose ofthis page is for you to recertify your EDS prior to submission to Cily Council or on the date of closing. If unable to recertify truthfully, the Disclosing Party must complete a new EDS with correct or corrected information)

RECERTIFICATION

with City Council crs. Not for City procurements unless requested.

This recertification is being submitted in conneciion with //^in - f / y / ^ / j ^ f'AYlC- cacj'drt^ AT' [identify the Matter], Under penalty of perjury, the person signing below: (I) warrants that /// ^ BlSl-itp he/she is authorized to execute this EDS recertification on behajf of the Disclosing Parly, (2) f o / ^ &y.fy warrants thai all certifications and statements contained in the Disclosing Parly's original EDS are true, accurate and complete as of the date furnished lo the City and continue to bc tme, accurate and complete as of the dale of this recertification, and (3) rcaffmns its acknowledgments.

mf lTt \ POLU<n/M / t f f ^ i /AJ C -(Print or type legal name of Disclosing Party)

Date: 10~1~ l3

PrniLor type irarrtc of signatory:

Title of signatory:

Signed and swom lo before me on [date] Ckf-ob-ft % 2iC?/3 , by ^€--(^ffey iKJ.'bV^A. at H-enn- 'p K County, r>^ ^ ^ gf)0• ' [state].

^ f ^ O t - - - - - Q y ^ O y \ a - < P ^ Notary Public.

Commission expires: [•^'bl - 1^

Vcr. ll-Ol-OS

SARA M. MALONEY U\ NOTARY PUBLIC-MINNESOTA

My Coititnission E»P*«"i?|i3j.f^

C I T Y OF C H I C A G O E C O N O M I C DISCLOSURE S T A T E M E N T

AND AFFIDAVIT

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/ if applicable:

Pullman Transformation, Inc.

Check ONE of the foHowing three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] the Applicant

OR 2. fc] 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: North Pullman 1l1th (NP 111) OR

3. [ ] a legal entity with a right of control (see Section II.B. I.) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 800 Nicollet Mali

Minneapolis, MN 55402

C. Telephone: 314-335-2560 Fax: 314-335-2568 Email: matthew.potter@usbank.com

D. Name of contact person: Matthew W. Potter

E. Federal Employer Identification No. ( i f you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Subdivision application for property generally located at 720 East 111th Street

G. Which City agency or department is requesting this EDS? Department of Housing and Economic Development

I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION H D I S C X , 0 S X ; K E o r 0"WNERSniP liNTERESTS

A.• NATURE;OF TJIE DISCLOSING PARTY

U liidicalc Ihu nature ofthe 'Disoldsing I'arlyr • i J Pcnott { ] Publicly registered b.usijicss corpomiion

Privo(cl)'held business corporation I ] Splo proprietorship. [ ] Gcaeiol partnership [ ] Liluitctl partnership [ ] Trust

[ J Limited liability company . [ ] Limited liiitjilily partnership [ 3 Joint ventiiro ( ] Not-ror-pTofit corporation (Is llic not-for-profit corporation also a 501Cc)(3))?

n Yc3 [ ] N o . [ ] Other (jslease specify)

2. For legal entities, tbc state (or foicign cotintryj of iworporaticii or organiznlion, if applicable:

3, For legal entities uot organized in the State of lliinois: Has the orgiin}:?atiQn registered lo do busiacss in the State of Illinois as o forolgfl ciitily?

[ ]Ycs ^ N o [ ] W A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

1. Lisl bclov/ the full names and Litlcs of all cxocutivo ofQccrbi and all directors of lire cjittly, NOTE: For not-far-profil corporntioos, also list below oil members, if any, which arc legal entities. If tljcro ore jno such iticmbcrs, write "no members." For trusts, estates or other similar entities, list below the legal titlch.oidcr(s).

I f the enlity is a general partnership, limited partnership, limited liability company, limited liability partnership or Joinl venture, list below the name and title of each general partner, managing member, manager or any other persoii.or entity that control,'! tlic day-to-day raanagcmentof the Discio.sing Party. NOTE; Each legal entity listed below must submit an EDS on its own behalf.

Name Title *

2. Please provide the following itifonnalion concerning cnch person or eniily having a direct or indirect beneficial interest (including owocraliip) in excess of 7.5% ofthe DL-iclosing Party. Examples of ."juch an inleresl include shares in a corpoialion, purtnorsbip inierest in a partnership or jotiil vcntyrc.

Page 2 of n

PULLMAN TRANSFORMATION IMC. OFFICERS

Terrance R. Dolan-Lisa L. Glover John P. KinseUa. Laara F. Bedinar.ski Matfliew B. Krush Jeffrey W. Shea Brett E. Scribner Cara L. Seeley

Prcsidcfit nnd Treasurer Senior Vice President Senior Vice President Senior Vice President and Secretaiy Vit:e President.and Assistant Secretary Vice President and Treasurer Vice President Assistant Secretary

'ntercst of a member ormanngcr in a'liinitcd liability company, oc interest of o bencficiniy of a trust, estate or other siniiiar entity. Tf none, .state "Nono." NOTE: Pursuant to Section 2-1.54-030 oF lhc Municipal Code of Chicago ,("Municipal CoH.o"), the City may require any such additional jnformation from any applicant whitili is reasonably intended to achieve full disclosure.

Nnmc >Jtisincss AU.Qrcss Disclosing Parly Percentage Tnierost in the

SECTION TTT --TiUSINESS RELATIONSHIPS WITH CITV ELECTED OFFICIALS

Mas the Disciosing Party Iiad n "business rcbtionship," ns dc0ncd in Chapter 2-150 ofthe Municipal Code, with any .City elecied official in the 12 montlis before the dnto this EDS is signed?

[ ]Ycs [sfNo KA'.i«'»-^-P(^fe,

I f yes, please identify below the numc(.s) of such City electedpfficial{s) and describe such Telationship(s);

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address.ofcach subconlractor, attorney, lobbyist, nccounlnrit, consultant and any other person or entity whom the Disclosing Party lias retained or expects to retain in connection With ihc 'Matier, as well as the niitnrc of the relationship, nud the total amount of tho fees paid or estimated lo bc poid. Tl ** Disclosing Party is not required to disclose employees Wlio are paid solely through tho Disclosing Party's regular payroll.

"Lobbyist" moans wiy person or entity who undcrtalccs to influence any legislative or adminislraliye action on behalf of any person or eniily other lhan: (1) a not-for-profit enlity, 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 ndneinistralive action.

If tho Disclosing Party is unccrtairi wlKtlicr ll di.tclosuro is required under ihi.s Section, lhe Disclosing Party musl citlicr n.ik the City whether disclosure is required or make the disclo.suri:.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Party 'Fces:(indicate whether retained or anticipated Address (stibcontractbri.attorney, paid or cstiriiatcd.):NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

' l loc^v^uM&^^t^.iVirt-C'^ not an acceptable response.

*f A .,'tr l.t 'i I ' i < - r < y 1 \

ctttrivontri-t

(Add sheets if necessary)

[ ] Chec!< here i f the Disclosing Party has not retained, aor .expects to retain, any such persons or entities.

SECTIOiN V ~ CERTIFICATIONS

.A. COURT-ORDERED CHILD SUPPORT COiVlPLLii.NCE

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

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child.support obligattons by an:y Illinois court ofcompetent jurisdiction?

[JYes [ ] N o J<i5 No person directly or indirectly owns 10% or more cf the Disclosing Party.

If "Yes," has the person entered info a court-app roved agreement for payment of ail support owed and is the person in compliance with that agreement?

[ ]Yes [ ] N o

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'busincss") 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 cunently 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, fi-aud, 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 1 applies to the Applicant, the permanent compliance timeframe in Anicle I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if Uic Disclojing Party is a legal entity, nil of those persons or entities identified in Seclion I I .B . I . of this EDS:

a. arc not presently debarred, suspended, proposed for dcbanment, declared ineligible or voluntarily excluded from ony transactions by any federal, slate or. local unit of goverjimcnt;

,.b. have iiot,within a five-yeurperio*! preceding lhe dale of lliis.EDS, been convicted of a crirainol offense, fidjudgcd guilty, or had a civtl.judgmenl rendered against tlic'm in connection with: obtaining, attempting lo obtain, or pcrformihg a public (fcdcrni, slate or local) trnnsnctioo or contract under n public transaction; a violation of federal or state iinlLtrust statutes; fraud; embc2zli:mcnt; theft; forgery; bribery; falsificatidn or destruction of records; making false statements; or receiving stolen property;

c. arc not prcHcnlly indicted for, or criminally or civilly chni-gcd by, .i governmental entity (federal, stale ur local) wiih cominitling any of the offenses set forth in clause B.i.b. ofthis Section V;

d. have not, within n five-year period procodiag the date of this liDS, had one or more public trausactioris (fcderal. slatc or local) terminated for cause or dufaiik; and

c. have not, wilhiu a fivc-ycar period preceding the date of Ibis EDS, been convicted, adjudged guilty, or found liable Iii a civil pfoceeding, or in any criminal or civil nclion, including actions •concerning cnvironmcntal violo.tions, initirutcd by the City or by the federal government, any istale, or uny other \m3l of local govcnimc'nt.

3. The ccrtificolions. in subparts 3, 4 and 5 concbm;

• the Disclosing Parly; • any "Conlnictor" (meaning any contractor or subcontrncar used by the Disclosing Party in

Connection with tlve Matter, including but not limited to all persons or Icga) entities disclosed under Section IV, "DLiclosurc of Subcpnlractor.t and Othcr.Rctainod Parties"); • any "Affilielcd Enlity" (meaning a person or entity that, dircclly or indirectly: controls tho

Disclosing Party, is controlled by tho Disclasing Party, or is, with tho Disclosing Party, under common conlrol of another person or entity. Indicia of control include, without limiliitioh; interlocking managenienl.or ownership; identity ofinlcrcsls aroong family members, shared facilities and equipmcdt; common use of employees; or orga.nizntion of a bu.iiacss entity foUbwiug the Ineligibilily of a business enlity lo do business with, federal or state or local govemmeni, including the City, usijjg substantially the jiamc management, ownership, or principals as the ineligible entity); with reispect tb Contractors, the term Affilintcd Entity means u person or entity that directly or indirectly controls tbe Contractor, is controlled by it, or, v/itb llic Conlraclor; is under common control of another person or entity; • any responsible official ofthe Disclosing Parly, imy Contractor or ony Affiliated Entity or any

other official, agent or employee of tlic Disclosing Parly, nny Contractor or any Affiliated lintity, acting pursuant to the direction or aulhorii:nlion of a responsible official of theDisclosing Party, any Contractor or any Affiliated Entiiy (collcctivoly "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Conlractor, iior auy Affiliated Eptily of eilher Ihc Disclosing Party or any Conlrnctor nor any Agents hiivcj during the five ycars.bcforc the dale this EDS is signed, or, with respect to a Contractor, an Afniiate'd Entity, or an Affiliated Iiiitity of a Contractor during the five years before the date of such Contractor's or Affdia'ted Entity's contriict or engagement in cotiueclion with lhe Molter: •

a. bribed or attempted to bribe, br bcsn convicted or adjudged guilly of bribery or attempting to • bribe, a public officer or employes ofthe City, the. State of Illinois, or'nny agency of Ihc federal •govcrnracnt dr of any state or local government in the United States of America, in that officci's or employee's.ofncial copncity;

b. agreed or colluded witli odicr bidders or prospective bidders, or been a party to any such agrecraeni, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective biddoj-s, in resliainl of freedom of competition by agreement lo bid a fixed price or otbcTWiso;or

c. made an admission of such conduci described in a. or b. above that is a matier of record, but have nol been prosecuted for such condncl; or

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

4. Neither the Disclosing Party, Affiliated Entiiy ox Continctor, or nny of their omployccs, officials, agunts or partners, is barred from contracting with »ny unit of sl.itc or local government as a result of engaging jn or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS S/33E-4; or (3) any similar offense ofauy statcorof ihcUiiitod States of ' Ainericu that contains lhc samo elemenls as lUe offense of bid-rigging or bid-rplating.

5. Ncilber the Disclosing Party nor any Affiliated Eniily is listed on any of the following lists maintained by tbc OTfico of Foreign Assets Conlrol of iho U.S. Department of the Treasury or tho Bureau of Industry nnd Security ofthe U.S, Department of Commeroc or their successors: thpSpecinlly Designated Nationals List, the Denied Persons List, the Unverified List, the Entity Lisl and thfe DeborredLiat.

6. Tho Disclosing Party understands and shall comply with tho applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) nnd 2-156 (Govtmincntal Ethics) ofthe Mimicipal Code.

7. If lEie Disclosing Party i.s unable to certily to any of the above statements in this Pari B (Further Ccrtificnticns), the Disclb.sinf Pariv niusl explain below: '

' •• hv ., •• _••

Pago 6 of 13

I f the letters "NA," the word "None," orno response appears on lhe lines above, it will bo conclusively •presumed that the Disclosing Patty certified to the above statcnicnis.

8. • To the best of the Disclosing Parly's knowledge after rcasonnbl.e inquiry, lhe following is n . complete list of ail current employees of tlie Disclosing Party who were, at any time during the 12-mdiith period prccctling the cxccution'datc ofthis iiDS, an employee, or elected br appointed official, of the City of Chicago (if none, indicnto with "N/A" or "none").

/l/^^fc- [Lfm^f^- ^ :

P. To tho best ofthe Disclosing Party's knowledge after rcasonnblc inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused lo bc given, at auy time during the l2-moath period preceding tlie execution date of tliis EDS, to an employee, or elected or appointed _ p f . -*-_ r _ r . 1 , _ i_, _ r / n i . J r? . . . . . . ^ . . . . . . . . A f t . r » . . 4 n f m .

— W -"J •""•ta

made generally available to City employees or to the general public, or (ii) food or drink provided in tho course of official City business nnd having a. retail value of less than $20 pcrrecipienf (if none, indicate with '"N/A" or "none"). As to any gift listed below, please also list the name of Ihc.City recipient.

^o/'to \L^^v t t / J , ;

C, CEjS.TIFICATION Ol-" STA'fUS AS FINANCIAL INSTITUTION

1, The Disclosing Party certifie.-i that Iho Disclosing Patty (chuck one)

[]i£ i)6isnot

a "financial institution" ns defined in Seclion 2-32-455{b) of tlw Municipnl Codc.

2, I f ll»o D isclosing Patty IS .t finnneial lustUutiou, then tho Disclosing Parly pledges:

"We arc.nol nnd will aot become n predatory lender as defined in Chapter 3-32 of the Municipal Code, Wc further pledge tliat none of ourafflllotes is, and none of them will become, a predator/ lender as defined in Chapter 2-32 of Ihc Municipal Code. Wcundcrstaad that becoming a prcdnlnry lender or becoming aa affiliate of a predatory lendor may result in the loss of the privilege of doing business wiih (he City." . ,

I f the Disclosing Party is unable to make (his plbdgc because i l or any pf iis alfiliatcs (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 hero (attach additional pages i f necessary):

Page 7 of 13

I f Ibc letters "NA," lh(> word "None," or no response appears on. the linos above, it will bc . conclusively presumed that the Disclo.'sing Parly certified to Iho above statements.

p . CERTIFICATION REGARDING INTEREST I N CITY BUSINESS

Any words or terms Uiai arc defined in Chapter 2-156 of the Municipal Code have the same meanings when usctl in this Part D.

. 1 . In accordanci with Section 2^156-110 of the Municipal Code: Docs any official or employee of the City have n financial interest in his or her own name or in the name of any other person or enlity in llic .Mutter? - ( 1 -ff^^^ f^-c-^^ < P O ^ ^ )i>o wi-trP&fc,

NOTE: I f you checked "Yes" to Item D.l . , proceed to Items D,2. andD.3. Ifyou checked "No" to item D.l . , proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no Cily elected official or enjploycc shull have a financial interest in bi.t or her own name or in the nume of any other person or entity in the purchase of any prdpcity lhat (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 tbc City (collectively, "City Property Sale"). Compensation for property taken pursuani to Uic City's eminent domain power docs not. constitute a financial intcre.H within tho meaning ofthis Part D.

Docs lhe Matter invplve n City Property Sale?

[ ] Ycs . l ^No

3. Ifyou checked "Yes" to Item D.l . , provide tliC naines nnd business addresses bf Uia City officials or ernployecis having such interest and identify the nature of such interest:

Name Business Address Natiiro of Interest

4. The Disclosing Party further certifies that no prohibited finat>cial intCTOst in llie Matter wil! bc acquired by any City official or employee.

E. CERTCICATION REGARDING SLAVERY ERA BUSINESS

Please check cither 1. or 2. below. Tf the Disclosing Party checks 2., the Disciosine Party musl disclose below nr in an altachmcnt to this EDS all information required by paragraph 2. Failure to

Page 8 of 13

eomply with Ihcse disclosure rcquiiemcnls may jnakc; any contiact cnipred into <"iih the Cily in connection with the Mutter voidable by ihc City.

_ j ^ - . l . The Disclosing Party'verifies'that the Disclosiug Parly has searched any and nil.records of the Disclosing'Pafly arid auy nnd .all predecessor entilies regarding records of investments or profits from slavery or slaveholder in.surauco policies during tiie .slavery era (including iiisur.incc policies issued to sinvcholdcrs ibat provided coverage for damage to or injury or death of Iheir slaves), and the Disclosing Party has found no such records,

^ 2. Tho Djsolosbig.Pnrty verifies that, as n result of conducting ilic scorch in step I above, the Disclosing Party' has found rc'cords'of investments or profits from slavery or slaveholder insurance policies'. The Disclosing Party verifies that the follq-wing constitutes full disclosure of all such records, including the names of ony and atl slaves or slaveholders described in those records:

SECTION Y I - CERTmCATlONS FOR FEDKRALLY FUNDED MATTJERS

NOTE:.If the MaCtcr is federally funded, complete this Section VL tf tlic Matter is not federnlly funded, proceed lo Section VIL For purposes of lliis Section VT, tax credits allocated by tho City and proceeds pf debt Dbligaiion.1 of jlhe Cily arc not federal funding. //.oT /^t(7o^-^'-V' T'-'f^^^^i

A; CERlTilCATION REGARDING LOBBYING

1, List: below tho names of all persons or entities rcgislcretl under the federal Lobbying Disclosiire Acl of 1995 wlio have made lobbying contacts on behalf of the Disclosing Party with rc.ipcct to the Matter: (Add sheets i f necessary):

(If no explanation appears or begins o» thc lines above, or i f the letters."NA" or i f lhe word "None" appear, it wi l l bo eonclusively presumed that the Disclosing Parly means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying cantacis qn behalf of the Disclosing Puny with respect to the Matter.)

2. The Disclosing Parly has not spent and will not expend any federally appropriated funds lo pay any person or cntity listed iu Paragraph A . l . above for his orhcr lobbying aedvitics or to pay any person or entity to infiuence or attempt 16 influence un officer or employee of any agency, us defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a incnibor of Congress, in conneciion with tho award of any fcdcraiiy funded contraci, matting ony federally funded grant or loan, entering into any.cooperative agreement, or to extend, continue, renew, amend, or modify any fcdcraliy funded contract, grant, loan, or cooperative agreement.

Pago 9 of 13

I I

.3. TheDisclosing Parly will subrnil sm updated corlification .at the cud of each calendar quarter in which there occurs any event that.materially affects, the accuracy of lhe statements and information set forth iri paragraphs A.L-and A.2. ab'ovii.

4. .Tiic Disciosing Parly oeriincs that ciiLcr: (i) U is not an orgriiiizriljori described in scclivn 501(c)(4) bf the Intemal Revenue Code of 19S6; or (ii) it is nn organization described in section 50 J (c)(4) of the Internal Revenue Code of 1936 but has not engaged and wilindt engage i i i "Lobbying Activilics".

5. I f the Disclosing Parly is lhe Applicant, the Disclosing Party must obtam certifications equal in form and substance lo paragraphs A - l . through A.*!, above from all subcontractors before U awards auy subcontract ond tlio Disclosing Parly niusi maintain all such subcontractors' cerlificalions forthe duration df the Mailer and must make such certifications proiaplly available to the City upon request.

. B. CERTIFICATION REGARDING EQUAL E.MPLOYMENT OPPORTUNITY

I f tho Matter is fcdcraliy fundud, federal regulations require the Applicant and all proposed subcontractors to submit the following informalion with their bids or in wriiing nt the outset of

.negotiations.

Is tlio Disclosing Parly the Ajiplicant?

[ j Y o s ^ N o

I f "Ycs,^' answer the llirffc questions below;

1. Have you developed and do you have on file affirmative nclion progroms pursuant to applicable federal regulations? (Sec 41 CFR Part 60-2.) • [JYes []lSo

2. Have you filed with the Johit Reporting Commillcc, ihc Director of Ihc Office of Federal Contract Compliance ProgramSj or tho Equal Employniont Oppormnity Commission all rcpbrla due under Lhe nppliciible filing requirements? '

I]Ycs HNo •

3. Haye you participated in any previous coniracis or suhconlracts .subject to the equal opportunity clau.'ie?

[ ]Ycs • [ ] N o

Ifyou checked "No" lo question 1. or 2. above, please provide an explanation;

Pnge IOof 13

SKCTION V I I - ACKNOWLIJDGMEWTS, CONTRACT T N ' C O R P O R A T I O N , COMPLIANCE, PENALTIES, DISCLOSURE.

The Disclosing Party undorslund.s nnd agrees, that:

A. Tho certifications, disclosure!;, and acknowledgments cdntainc.d in-this .EDS will hocotne part ofauy contract, or other agreement between the Applicant nnd tho City ih connection wiih the Matter, whether procureiiient. City assistance, or other City aciiori, and tire malcrial inducenicnts to lhe City's execution of any coritriict or takhig olher nclion with respect to the Maitcr. The Disclosiiig Parly understands lhat it must comply with all statutes, ordinances, and regulations bn which this EDS Is based.

'B. The City's Ooycmnicntal Ethics and Campaign Financing Ordinances, Chapters 2-156 (ind 2-164 of the Municipiil CoJc, impose certain duties and obligations on persons or entities seeking City coiitracts, work, business, or Irnnsnclions. The ful l text of these ordinances aud a Iraialng program is available on. Hue at wwsv.ciiyofchicaao.ora/Sthics. and may also he obtnincd from tlic City's Board of Ethics, 740 N.

Sedgwick Sc., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Parly must comply fully with the applicable ordinances,

C. I f the City.detbrrojncs lhat any infonnntion provided iu this EDS is false, incompic'to or inaccurate, uny contract or other agrccmcul in connection with which it is submitted miay be rescinded or be void or voidable, and tho City may pULSucnny remedies uridcr the contract or agiecraeiil: (if not rescinded or void), at law, or in equity, includhig terminating the Disclosing Party'.i participation in tlio.Maltcr und/or dccliniiig to allow tlic Disclosing Party to participate in olhcr transactions with the City, Retricdics nt law fora false .stptcrncut of material fact may include iucacceration and an award lo the 'City of treble damages.

D. It is the City's policy to make tliis document available to ihe public on its Internet site nod/or upon request. Sonjc or all ofthe information provided on this EDS and any attachments to this EDS may bo made available to the public on the Internet, in rcspoii. c to a. Freedom oTInfomialion Acfrcqucsl, or otherwise. By compleiing and signing.this EDS, the Disclosing Party wnivcs and rclcnacs 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 accur.icy of any informalion submitted in this EDS,

E. The informalion provided in this EDS must he kept current. In lhe event of changes, the Disclosing Parly must supplement Ihis EDS up to the time the City takes action on the Maitcr. I f lhe Matter is a contraci being handled by lhe City's Departrucnl of Procurement Services, the Disclosing Party must update Uiis EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 of the Municipal Code (imposing PERlVfANENT INELIGIBILITY for certain specified o ffcnscs), lhe information provided herein regarding cligibillly must bc kept current for a longer period, as required by Chapter 1-23 and Section 2-!S<1-020 of the Municipal Code.

The Disclosirig Parry represents and warrants lhat:

Page 11 of 13

F. l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Departinent of Revenue, nor are the Disclosing Party or its Affil iated 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 Affihated Entities w i l l 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. Genera) Services Administration.

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wi l l 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 wil l 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 certificafions.

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.

C E R T I F I C A T I O N

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 fumished to the City.

(Prinlfbif tyjJe^me of Disclosing Party)

(Print or typ me of person signing)

(Print or type title of person signing)

sssS^SSSSS33SSSSSSSSSSSSS3S

SARA M. MALONEY NOTARY PUBLIC - MINNESOTA

My Commiseiort Expires Jan. 31,2015 j

Signed and swom to before me on (date) TU. V I at ffenA-gpM County, m ^A^^Sc>i^statl).

Commission expires: \ " 3 I ^-^

Notary Pubhc.

Page 12 of 13

CITY o r CHICAGO ECQj^OMlCiDISCLOSmyj STATEMENT AND AFFIDA VIT

APPENDIX A

. FAMILULMLATIONSHIPS WITH ELECTED CITV OFPICIALS AND DEPAKTMEMT,HEADS

This-Ajipcndlx Is to be completed only l>y (a) the Applicnni, And (li) .any Icgnl entity which has n direct o-wncrsblp mlqrcstin tho Applic.int cicctding 7.5 percent. Itis not to be.completed by any legal entity which has only an hiilircct ownership lntcre,";t in tho Applicant.

Under Municipal Code Section 2-l5'l-01S, the bisclo'sliiB Parly ttiust disclose whclliur such Disclosing-P;iTly or any'"AppIicable Party" orany Spousb or Domestic Partner thereof currently has a 'Tnmilial ydatioiiship'* wiih aiiy elected city ofllejul or deparlraenthEad, A 'Tuniilial celalionship" exists if, as of tlie dale liiis EDS is

f . t . ~ r N ; 1 . . . : - n . . ^ . . ' . . ' . . . . . . . . M , \ _ ' . . . 1 : _ ^ U I A . K U t f . . . . , , . . . . . . . . ' r t n « n . . . J » t l . . U . . n . . I n r A l f l

the mayor, nny aldcnnnn, the city clerk, the city treasurer .or any city dcpartiiicnt hend as spouse or domestic partner or 05 anyofUic.following, whether, by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, fathcr-in-lnw, mothor-in-lew, son-ht-la\y, daughler-in-tav/, stepfather Or stepmoilier, stepson or slepdnughtcr, .itcpbrother or sfcpsi.itcr or hnlf-brothcr or hull-sistei;.

"Applicable Party" meiuis (1) all cxecUlive ofTicers of the Disclosing Party listed in Section H.B.l.a., i f llie Disclosuig Party 15 a corporation; nil partners of tlic Disclosing Party, if tlic Disclosing Party is a general partnership; till general partners ond limited 'panncra of the Disclosmg Parly, if llic Disclosui.g Party is n limited partnership; all managers, naiuuiging members and members ofthe Disclosing Parly, if the Disclosing Party is a limited liability compaiiy; (2) all principal officers ofthe Discio.sing Party; tind (3) any person having morc.tlian -n 7.5 percept osvnership interest in the DiRclosingParty. "Principal oEDceis" nieans the president, chief operating officer, executive director, chief financial oOicisr, treasurer or sccrcuiiy of a kgal entity or any person exercising similar autliority.

Docs liic disclcsing Party or any "Applicable Parly" or uny Spouse or Domestic Ppclner thereof curccnily have n 'Tamilial relationship'.' with an clccjcd city official or department head?

E1 Yc5 p<l No p f^rc-f-- .V<~^f- K(? M)' Y

If yes, please identify below (1) the name and title of such per.Ton, (2) the name ofthe legal entity to which such person is cmiiicctod; (3) Ihe.narau atid title of the elected city official or department head to whom such person has a familiol relationship, and (4) the precise r.alure of such familial relationship.

Page 13 of 13

(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose ofthis page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfiilly, the Disclosing Party must complete a new EDS with correct or corrected information)

RECERTIFICATION

Generally, for use with City Councii matters. Not for City procurements unless requested.

At^t^mttiT •n> pi>ti<*n *- so52>tVISION or This recertification is being submitted in connection with /AHIQ'- ffj/jjy\MO f/tfi.C- coc/fV^ [identify the Matter]. Under penalty of peijury, the person signing below: (I) warrants that /// ^ "^BlStHP ho/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) foKJ) <SX^/ warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date fumished to the City and continue to be true, accurate and complete as of the date of 'his recertification, and (3) reaffirms its acknowledgments.

(Print or type legal name of Disclosing Party) Date: //P-?-/^

Priyit or typep/lmc of signatory:

Title of signatory:

Signed and swom to before mc on [date] (Dclobt^ ^ ^ " ^ 3 , by T€.^rey U^. •She^. at |4iPrtn p7y^ County, m'in>l(^^<^[state].

Commission expires: I ""^ / - / 5 "

Notary PubHc.

Vtr. ii.oi.os

SARAWl. MALONEY M NOTAIIY PUBLIC-MINNESOTA ' 0 MyCommi5sioiiExpir9SJa|i 3

C I T Y O F C H I C A G O E C O N O M I C 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 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:

U.S. Bank National Association

Check ONE ofthe foiiowing three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] 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. P l a legal entitv with a rioht of cnntrnl (se.p. Section II.B. 1.1 State the leeal name of the entitv in which the Disclosing Party holds a right of control: Pullman Transformation, inc.

B. Business address of the Disclosing Party: 800 Nicollet Mall

Minneapolis, MN 55402

C. Telephone: 314-335-2560 Fax: 314-335-2568 Email: matthew.potter@usbank.com

D. Name of contact person: Matthew W. Potter , _ .

E. Federal Employer Identification No. (if you have one): '

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Subdivision application for property generally located at 720 East 111th Street

G. Which City agency or department is requesting this EDS? Department of Housing and Economic Development

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Vcr. 01-01-12 Page 1 of 13

n li^\>>

SECTtON I I -- .piSCLdSURE. OP OWls'ERSHI.iP INTERESTS-

;A. NATURE o f THE DISCLOSING PARTY

1, In(:iicatc; the nature of the Disclosing Party:

[ ] Person ^ Liinifcd iiiibilify cprnpiiny [ ] Publiely"rcgi.sfercd business corporation [ j Liriiifcd liability piiirfncirship [. ] Frivuicly heid b,usincs.s corporation [ j Joinl.vcnti.ire [ ] Sole propriclnrship f ] TvJot-f6r-pfpfitc6q)oration { ] .General'partnership (is the ndt-Tor-profit cdrporalibn also a 50i(c)(3))7 [ ] Li.'irjjtcd partnership Ycs' [ ] No [ ] Trust; ^ Other (please specify)

2. For Icgnl cjitiiieSj the stauc (or foreigri coiintty) of incorppraiion or orgnni7,ation,.if applicnblc:

'3. F6ir :lcgal criiftics hot organized in Ihc Slate of Illinois:. Has ihc organization registered lo do business in the State Of Ill)riois.,iis a foreign entity?

!VVes []N6 [iwk ;/f^rtA^^^

B. I F THE DISCLOSlis'G PARTY IS A LEGAL ENTITY:

1. List below the fu l l riajncs and titles of all executive officers and all dircclors of the eniily, NOTB: For not-for-profit.corporalionSy ^Iso list below nil memberi;,.if any,;\vhich arc lcg.il cntitie!;. I f iherc. are no-siich members, .write "no members." For trusls. cslates or other similar cnritiesi list bclo\v ihc legal lilleholdcr(s),

I f the. entity, is a general parlricr.ship, lii^iifcd partnership, liniiicd liability coinpany, limited liabiliiy partnership or joint ventlirc, list below thcnamcapd titlcpFcacxh.general partrier, managing: member, hiariiiger or any other person or cnrit)' that conirols ihc day-to-day maniaigcihcht of ihe.Disclo'sing Party. NOTE: Each legal enlity listed laclow must submit an EDS on.its ovyn behalf.

NaniC: Tilie^ filTMJ-lC:\i ^ ? S T

2. Please provide theTollchving infOrniation concerning each'person or entity having a direct or ind.ircet bcncfieial ihicrcst; (inciuding ownership) iti excess of 7-5% of. lhe Disclosing Party, Examples of such, an micrest iheludo shares in a corporation, partnership jritcirc.st.in a.piii^crship or joint venture:,

page 2 of 13

Attachment C

City of Chicago Economic Disclosure Statement and Affidavit

Statement Regarding Registration as Foreign Entity

U.S. Bank operates branches in trie State of illinois uiidt;i tht; authuiity of its national bank charter and is therefore not required to register as a foreign corporation with the State.

ifiti'e.'-: '• •;.V -f; ;'„", •.•=.••.-:••;•'•'•-••"•;"::'•'LI-V H' -SV " ^ ^

mmyc' r.'.''i^-y. •••••yyM^M^'y^B'^yyi&^&Mm^ Davis, Richard K. Director, Chainnan of the Board

Baker, Douglas M. Jr. Director

Belton, Y. Marc Director

Buynlski Gluckman, Victoria Director

Collins, Arthur D. Jr. Director

Hernandez, Roland A. Director

Johnson, Joel W. Director

Kirtley, Olivia F. Director

Levin, Jerry W. Director

O'Maley, David B. Director

Ovirens, O'dell M. Director

Schnuck, Craig D. Director

Stokes, Patrick T. Director

Woo Ho, Doreen Director

U.S. BANK, NA DIRECTORS

Davis, Richard K. Chairman, President, and CEO

Carlson, Jennie P. Executive Vice President

Chosy, James L. Executive Vice President, General Counsel and Secretary

Gifford, Craig E. Executive Vice President and Controller

Griffith, Kenneth (Randy) Executive Vice President

Hidy, Richard J. Executive Vice President and Chief Risk Officer

McCullough, Hovvell D. (Mac) III Executive Vice President and Chief Strategy Officer

Nelson, Kenneth D. Executive Vice President and Treasurer

Oldshue, Paul F. Executive Vice President

Parker, P.W. (Bill) Executive Vice President and Chief Credit Officer

Somers, Timothy W. Executive Vice President

Cecere, Andrew Vice Chairman andChief Financial Officer

Dolan, Terrance R. Vice Chairman

Elmore, John R. Vice Chairman

Hoesley, Joseph C. Vice Chairman

Joseph, Pamela A. Vice Chairman

Payne, Richard B. Jr. Vice Chairman

Stone, Kent V. Vice Chairman

von Gillern, Jeffry H. Vice Chairman

interest of ^ member or managcr.'in a limited liability coinpany, or interest d fa beneficiary df a trust, e.statc or pther similar eiuiiy. I f ttonCi stale "None," MOTE: Pursuant io Scctipn.2--l:54-630:of the Municip:il Gbdc.of Ghicagd ("iVIunicipal Code"), the Gity may require ainystich additiorialinforrnation frpm any applicant.\yhich is rcuspnab|y intended to nehicvc fulldisclpsure.

Name Business .-\ddrcss Percentage Interest in the

_ ^ Soo M i c o i ^ C y / ^ i ^ Disclosing: Pi^rty

SECTION I I I - BUSINESS RlSLATIONSUlPS WlTJl. CITY ELECTED OFFICIALS

Has the Disclosing Party had a "business rclatiohship,'' as'dcOncd in Chapter 2-156. of ihc Municipal Code, wiih any Gity elecied official in ihc 12 montlis before .the date ihis EDS' is signed'?

I fycs , please identify below Lhe rr;nnc(s) of such Gitry elected official(s) and describe such relnt{6nship(s)'

SEGT10,^f IV DISCLOSURE OF SUBCONTRACTORS AND OTHER R E T M N E D PARTIES

The Disclosing Party mu.sl discto.se thc nqnie and business addrc.Ss of caeli sutconlT.Tctor, attoniey, lobbyist, acconnlant) consultant and'any .other person or entity whom the Disclosing Piii^'has retained or expects to retain .in conncetibn with the .Matter, ns well as the naturc 'o f the relationship, and ihcr tolal amountrPf the Fces paid or csiimited to be paid. The Disclosing Party is .riot rocjuired to disclo.se crnployccs Avho arc paid soicly tlirough tbe Disclosing Parly's regular payroll,

"Lobbyist" means any porsori or.pntitj' who undt^rtakts. to influence any legislative or adraiDistraiiyc action on behalf of ariy pcrsoti or-cmity othcrthan; a npt-foti-prorn. entity, on an unpaid b.isis. or (2) himself, "Lobbyisi" also mean.s any person or entity any parf o f whose duties as an employee of another includes undertaking to influiince Tiny legislative or administrative action.

I f the Disclosing Part ' is linccrtain whetlier a disclosure is required liiidcr this Secliori; the Diselas.ing Part3'must cither ask the. City wbcthcr di.sclosure is required or make the discltisurc:.

Page 3 of 13

N'amc (indicate whetlier Business, Kclaitionshi'p to Distlosihg Party Fees (indicate whether retained.or anticipated Address (subcontractor, attorney, to be retained) lobbyist, etc.)

paid or estiinatcd.):NGTE;. "'hourly ratfr" br "t;b,d." is. not an acceptable response.

f O O P

(Adci sheets; i f necessary) -rTLfhti^/e-mprnaftit l/JC y s. jsA^t^ AX-A,,

. .A)->v> ^A>^fi_f p^//^ fzfi^Tn 9"^"^^^ \i^'^''>i [ ] eheck h ere: if the Disclosing Party has not retained,, nor expects.to retain, any suchpersons or entities, if^^ •

SECTION V — CERTlFiCATIONS

A. C O U R T T O R D E R E D . C H I L D S'UP.R0RT GOMPLIANCE

Under M unicipal Code Section 2-92-41:>, substantial, owners of business entities tliat contract with the Gity must remain in compliance witir their child suppprt.p.bligatio.ns thi^oughput the contrae terra.

Has any persbii who.directly or indirectly owns-10% or more of the Disclosing Party been declared in arrearage on any child-support obligations by any Illinois court of coriipetcnt jurisdiction?

[ i Yes [ ] HQ: ^ No person directly or indirectly owns 10% or more of the P IS closing Party.

If "Ycsv" his the person entered into a court-approv.ed agreeiilcnt for paymentof all support owed and is the person in ebnipliance.Avith tibat agreement?

[JYes [ ] N o

B. FURTHER. CERTIFICATIONS

I . Pursyant to Municipal Code.Chapter 1-23, Article 1 ("Article r')(which the Applicant should consult for defined terms (e.g;, "doing .business'') and legal requirpments), i f thC; Disclosiiig Party subtnitting this EDS is the Applicant: and is dping business with the Cityj then the Disclosing Party certifies asi follows:, (i.) rieithisr the Applicant nor any contrbllin* person is currently indicted or charged with', or has adrtiitted guilt of, or has ever been convicted of, or placed under stipen'ision for, any crirnihal offense involving actual, attempted, or cpnspiracy ito commit bribery,.theft, fraud, forgery, perjury, dishonesty or deceit agEuinst an officer or einployee of the City or any sister agency; and (ii) the Applicant uridefstands and aclai6w.ledg« that c6rnpliahcc.wi Article I is a! co:)itiniiing;requiremeiit.for doing business with'the City. NOTE: I f Artic.le:rapp.lies tb the Applicant, the petrnanentcompliance timeframe iri Article: I'supersedes some five-year compliance tinieframes rn certifications'2 and 3 below.

Page4 of 13

2: Tlic Disclosing Party and, i f the Disclosing Party is a legal entity, all o f those pcrsoiis.orcnlititS identified ih Secfion II-B,1;. of this EDS;

a, are:not prespritlydebarred,, s^^ proposed for debarnient, declared ineligible orA'pluntariLy excluded from ariy tfahsactioris by any federal, staile or local unit of goviimmeht;

b. have. npt,. Willi in a ilvc:.^year period preceding the dale ofthis EDS, been convicted of a criminal offense, adjudged guilty, orhad a civil judgincnt rendered against Ihem in connection.with; obtaining, aitchipiiiig.to obtain, or pcVfdrinihg a.j3i)blid.(fcdcra],.stdte or local) transaction or canfractundcr a p»i,bfic transaction.; a. violation of federal or .stale aiilitrusl statutes; fraud; cmbtizzltjinenrifdie-ff;. fofgery; briber>'; falsification oi" dcstrticiiori. df records; mnkingvfal.se sliitcnicnts; or receiving stplcn property;

c, arc.not prosently in.diclcd for, or criminally or ciyi l j j ' chargcd by a. governmental encir>' (federal, state or local) With.cbmmiiiirig any ofthe offenses sciTorlli in clniisc D.2.b. ofthis Sccliori V;

d. - hive not. ivithiii 2. five-ye2r pcnpd- preceding the date o f this HDS, hsd one or more public" trdnsactions (federal, stale or Jatal) terminated for cause or default; and

.c. hiive not, wilhma'fiyc-year period prcccdihg Ihedatc prthis E.DS, been cpnvi'etcd, adjudged giiilty, or foimd liable in a civil procceding, pr'iiS any cnmin^ nclion, inchidin^ ficlioiis concerning environmental violatiotr.s, instituted hy the City or by thcTcdcrai government, any state, or any other unit; df local gpvenimcn t;

3;. The certifications in siibparts 3; 4 a.iitl 5 concern:

• the pi'sclosing Party; • any ".ConLfsiclpr" (meaning any contractor or subcontractor used by rhc Disclosing Party irt

cbiintciibn with the Hatter, includirig but nor.liiTiitcd to all pcrsdns or legal entities diseldiicd tinder .Scc.tion.-.iV, "Disclosure of Subcpatraclors arid Olhcr Retained Parties");.

• any "Affiliated. Entity" (nicaning a piirson or entity tliat,.directly or iridircctjy: cpntrdls tlic Disclosing Party, is cpntrolled by the Disclosing I'arty, oris, with the;Disclosing Party, under com.mpn control of another person or entity. Indicia, of corrtrol include, without liiriit^tion;' interlocking management or ownership; identity of interests among family members, shared facilities; and cqurprncnt; cpriirapn use of employees; or organization of a Ijusincs;; eniily follow'ing ihii ineligibility of :t business entity to do business with federal or state or local government^ including Ihd City, uisirg substantially the same management, ownership, or principals as the ineligible cniity); with respect tO: Conlractprs, the terra Affiliated Entity mcans;a pcrison or eniily that dircctjy or indi^rcctly cpriirols the 'Cbntirictor, is cohtrplled by it, or, with the Contmctpr,. is binder common control of anoihOr person or.entity;

> any ^sponsible official o f fche:.DiscloSing Party, any Coiitractor.di' any Affiliated Entiiy.or any other official, agent or cmplpycp ofthe Disclosing Party, any Contractor or any Affiliated Enlity, ?icting pursuan|.ip;th'e dircclibii or authbrization of a rcspohsiblo official bf ihcDisclosing Party, any: Contractor or any Affiliated, Entity (cpll.cctiveiy "Agents").

page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or atternpting to bribe, a public officer or employee of the Cily, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar oiTense 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 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 of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below: See Attachment "B" in response to Section V-B-2-(e). No other exceptions to certifications.

Page 6 of 13

Attachment B

City of Chicago Economic Disclosure Statement and Affidavit

Statement Regarding Further Certifications

U.S. Bank National Association itself is a mortgage lender. U.S. Bank National Association is also one of the largest corporate trustees in the United States and in such capacity is trustee of numerous mortgage-backed securitization trusts that each hold multiple real property mortgages. From time to time, mortgage borrowers in Chicago default on payment of real estate taxes or otherwise fail to comply with City of Chicago requirements with respect to certain of their mortgage properties. This can result in legal action against the borrower by the City of Chicago, which legal action may name U.S. Bank National Association as the mortgage holder (either in its individual capacity or in its capacity as a trustee). As of July 12, 2012, U.S. Bank National Association was aware of outstanding claims against it (individually or in its capacity as trustee) totaling $261,046.46 wherein the City of Chicago or one of its departments or divisions (including the Department of Buildings and the Department of Sanitation) is the creditor. The vast majority of this amount is related to properties that U.S. Bank National Association holds in trust and for which it does not do the servicing. U.S. Bank National Association, both in its individual capacity and in its capacity as a trustee meets with various City officials twice a month to address these claims.

I f liie letters "NA," ili.e word "None," or no response, appcurs on the lines aboye, it will be conclusively presumed that the DistiJo.sing Paitty ccrtifiiid tp the abbyc:s(aiiemenls.

T6 the best of the Disclpsihg Party's knowledge after reasonable inquiry, the following is a, complete list pral l currehii.empipyccs pf the Disclbsing Party who were, at any time during the I2-. month period preceding Ihc execution, date ofthis EDS, an crnployee, or elpctcd.or appointed official, b f the Gity o f Chicago ( i f n6nc,indicaic.with "INVA" or "none;").

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the-following is a complete list o f all gifts that the Disclosing Pairty has given Or caused to be givcrii Ut any time: during .the 12-monlh period preceding the execution date'.of this EDS, to an employee, or.c.|ecled or appointed official, of the Cily of Chicago. For purposes of this slatemcnt; a "gift" docs nol include: (i) anything made generally avaikbic:io Giiy emplpyees pr to ihc general piijilic, or (ii) food or drink provided in ihc course b f official City bu.siness and having a retail value oflcss than S20 pcrrccipicfnt (if none; inciicnte vvith "N/A" or "none"). As to any gif t listed bplow, please also list the name of ihe Giiy recipient.

G.. GGRTIFIGATION QF STATUS AS . f ^ A N C I A L INSTITUTION

I i The Disclosing Party ecriifies that the Disclosing Party, (check one).

^ i s ^ [ l i s rVol

a ''financial iiisiilutjon" ns defined in S.oclibri 2-.32-455(b).of the Municipal Code.

2. I f the Disclosing Party IS a fmancial institution, then the Disclosing Part ' pledges;

"Wc arc riot and w i l l riot become a predatory lender iis defined in Chapter 2-32 of the Municipal Code,-, Wc further pledge thai.none pf our affiHates. is, and none cf them wi l l become, a predatory lender ds defined in Chapter 2-32 ofthe Mimicipal Code. Wc undcrst.ihd that becoming a predatory Icnd.er orhccpming an affiliate pfa predatory lender may result in die loss of the privilege of doing bpsincss with tlie City."

i f the Discl6sirig;.Party is unable to make this pledge biicniiso it or ilny of iti; affiliates (as defined iri Section 2-32-45.5(b) of ihe Municipal Code), is a predatory lender within ihc meaning of Chaplcr 2-32 of the Ivf unicipal Code, explain here (attach addilioiia! pages i f iiecessary)r

fage-Vof 13

I f the letters "NA,."' the \v6rd "None," or no response appears on Ihc.lirics .above, it \v.ill be: con.chisivciy presumed. Ihat.lhc: Disciosing Party ccrtidcd to the nbpyc sin.temcnts..

D, GBRTIRIGATION: REGARDIKG INTEREST.IN CITY BU&mESS.

Any.Words.br terms that afcdeliiicd in Chapter 2-156:of the Klunicipal Godi; have; the same nricapings \yhcn used in this Part D.,

1,. In accprdance wilh^Scctipn 2.-15:6-1 IQ df the Municipal Code.: Does ariy official or employee of the City have a fiiiaiicia I interest, in his pc her owf* name pr rn the name of any other person Or caUty in.tiic.Matvcr? ^ -r(-<(=^ fi> t r > t ^t^^oiv^'--1 pG tr..

NOTE; Ifyou clieckcd "Yes''lo Ilcni D.l. , proceed to ticin^ D.2. and D,3. If you cllctkcd "No" to Item D.J„ prpcecd to Part E.,

2. Unless soldpursuant to a process of competitive bidding, or ptlierwiijc permitted, no Gity elected bfficial br employee shall have a finaaeial intcrcsl; in his or hct own name ot in the name of any other person or cniity in.the purchase of ariy property that (i) belongs to the City, or (ii). is sold for taxes or assc.ssrricnts, or (iii) is Spld by virtue of |cgal process at.ihe suit of the City (colfcclively; "Gity Property Sale"). Compensation for property takcft pursuani tb the City's eminent donflain power doc.'i not constitute a financial interest within the meaning of ihis Part D.,.

Does die Matter involve a City Properly Sale?.

[ .] Yes [ ] No.

3. Ifyou checked "Yes" to .hem D. 1., provide tlie names and business addresses of the Gity officials or cmp'ioyccs liayiiig such iiiUircstand identify the. nature pf Such interest:

Name' Business Address .Naliire of Interest

4: The; Disclosing Party funher certifies that no prohibited financial iritercst.in the Matter will .be acqiurcd by;any City pfficlal or criiploycc.

E. CERTIFICATlOH REGARDmG SLAVERY ERA BUSINESS

Please check cither 1. or 2. below; If the Disclosing Partyidiccks 2., the Disclosing Party must disclose below or in ari attachraerii.to this EDS all mfonnatip.n required by. paragraph Failure to

Pages 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.

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: Please see Attachment "A" and the letter dated April 29, 2004.

SECTION VI -- CERTIFICATJOINS 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 VI 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 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

Attachment A

City of Chicago Economic Disclosure Statement and Affidavit

Statement Regarding Slavery Era Business

U.S. Bank National Association vjas formed from the following major banks: (1) Star Bank, National Association (Cincinnati, Ohio) changed its name to Firstar Bank, National Association (Cincinnati, Ohio) effective February 1999; (2) Mercantile Bank National Association (St. Louis, Missouri) merged into Firstar Bank, National Association (Cincinnati, Ohio) effective April 2000; (3) United States National Bank of Oregon (Portland, Oregon) merged with First Bank, National Association under the title U.S. Bank National Association effective August 1997; (4) U.S. Bank National Association merged into Firstar Bank, National Association, and the succeeding bank, changed its name to U.S. Bank National Association effective August 2001. These banks acquired through mergers and acquisitions numerous smaller banks. There are five hundred and forty-two U.S. Bank National Association predecessors. Thirty-five predecessors were founded before the abolition of slavery in December 1865. Thirteen of the pre-1866 predecessors were established in southern slave-holding states and territories, including Kansas, Kentucky, Missouri, and Tennessee.

In reviewing historical records held in various external repositories in accordance with the research requirements as set forth in the City of Chicago Office of the Corporation Counsel opinion letter dated April 29, 2004 (attached hereto), U.S. Bank National Association has identified external records of its predecessors which necessitate disclosure. The conveyance records, while showing no record of direct ownership of enslaved individuals did contain records of founders and/or directors of predecessor banks owning enslaved individuals, as well as a record where an enslaved individual was the collateral for a loan. Specifically, the first president of predecessor Marion National Bank of Lebanon, Kentucky (founded in 1856), Benedict Spalding, owned two enslaved individuals in 1850. In 1860 someone with a similar name "Benidict Spalding" is also listed as having owned fourteen enslaved individuals. In addition, certain members of the Marion National Bank of Lebanon's board of directors (called "commissioners") owned approximately forty-seven enslaved individuals in total (the records include abbreviated names, which we conclude may be references to commissioners). The first president of predecessor First National Bank of Clarksville, Tennessee (founded In 1865), S.F. Beaumont, owned one enslaved Individual in 1860. The first president of predecessor Sl. Louis Building and Savings Association, Missouri (formed in 1857), Marshall Brotherton, owned ten enslaved individuals in 1850 and four enslaved individuals in 1860. Merchants Bank (founded in 1857) and Bank of St. Louis (founded in 1857), both predecessors, along with a group of other St. Louis firms, issued a mortgage to Charles McLaran that was secured by his property, which included an unspecified number of enslaved individuals. However, the 1860 Federal Census Slave Schedule for St. Louis provided that Chartes McLaran owned thirteen enslaved individuals.

The above is only a summary. U.S. Bank National Association has previously provided the City of Chicago with supporting attachments.

U.S. Bancorp, the parent company of U.S. Bank National Association, was founded after the slavery era and has no separate assets or activities that pre-date the 20th century. As such, it has no disclosure separate from that of the bank.

City of Chicago Richard M. Daley, Mayor

Department of Law

MaraS. Georges Corporatioa Counsel

CityHall. Room 600 121 North LaSalle Street Chicago, Illinois 60602 (312) 744-6900 (312) 744-8538 (FAX) (312) 744-2963 (TTY)

http://www.ci.chi.il.us

B tniDlUC CHICAGO TOGETHER

April 29, 2004

Hon. Edward M. Burke Chairman, City Council Committee on Finance r ' . t M U o l l D — ^ , - j m W i . J .1JL«X11, JLVV./VJJI11 . J t J X .

121 North LaSalle Street Chicago Illinois 60602

Re: Question regarding Economic Disclosure Statement and Affidavit, Part VI ("Certification Regarding Slavery Era Business") and Resolution pending before the Joint Committee on Finance and Human Relations

Dear Alderman Burke:

In a letter dated April 26, 2004, you indicated that a special committee of tlie City Council, consisting ofthe combined Committee on Finance and the Committee on Human Relations, currently has under consideration a resolution that raises certain issues regarding interpretation of Section 2-92-585 of the Chicago Municipal Code, the Business, Corporate and Slavery Era Instirance Ordinance. That ordinance requires every city contractor to "complete an affidavit verifying that the contractor has searched any and all records ofthe company or any predecessor company regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era. The names of any slaves or slaveholders described in those records must be disclosed in the affidavit." (Emphasis supplied)

The affidavit requirement of Section 2-92-585 has been incoiporated into the standard Economic Disclosure Statement ("EDS") completed by city contractors as Part VI, entitled "Slavery Certification." The EDS requires an entity contracting with the city to verify that it has "searched any and all records of the Undersigned and any and all predecessor entities for records of investments or profits fi-om slavery, the slave industry, or shareholder insurance policies." (Emphasis supplied) The EDS form then requires the contracting entity to disclose the results of that search.

You have asked specifically whether it is "reasonable to interpret the language 'records of the undersigned and any and all predecessor entities' to mean [the contracting entity's] records and the records ofits predecessor entities." For the reasons that follow, it is the opinion ofthis office that the answer is in the

Hon. Edward M. Burke April 29, 2004 Page 2

affirmative. A search required for proper compliance with and disclosure under Section 2-92-585 must include all known records of the contracting entity and each ofits predecessor entities, to which records the contracting entity has or can obtain access.

Neither the ordinance nor any Illinois decision defines a "predecessor" entity of a city contractor. Under the general rules of statutory construction, the word should be given its ordinary meaning. Black's Law Dictionary defines "predecessor" as "one who goes or has gone before; the correlative of 'successor' Applied to a body politic or corporate, in the same sense as 'ancestor' is applied to a natural person." This simple analogy indicates that every known antecedent entity of a city contractor — acquired entities, components of earlier mergers, entities acquired by and subsumed into a prior entity that became a predecessor of a contracting entity - should be treated as a predecessor. This is especially appropriate when one considers the preamble to the ordinance adding Section 2-92-385 to the Chicago Municipal Code. The fifth paragraph of the preamble (found at page 94891 ofthe Joumal of Proceedings of the City Council of October 2,2002) refers to records located in the archives of current insurance firms, documenting slave insurance policies "issued by a predecessor insurance firm; the sixth paragraph (zc?.) refers to "insurers and businesses whose successors remain in existence today." Thus the City Council recognized that, as the American economy has expanded and become more complex, modem business may include different business disciplines (insurers and other businesses).

The appropriate extent of the mandated records search can also be discerned from the preamble. The final paragraph ofthe preamble (p. 91892) contains a finding of the City Council that entities "doing business with the City of Chicago shall take any and all steps in good faith to disclose any records 'within their possession or kno'wledge relating to investments or profits from the slave industry including insurance policies...." (Emphasis supplied) In order to implement this statement of the Coimcil's intent, a confracting entity may not ignore records that are archived outside the entity's possession {e.g. in a museum, university library, historical society or trade association). To ignore deliberately the existence of such known records could not possible constitute a "good faith" effort to take "any and all steps" to document the confractor's history. The breadth of the City Council's desired disclosure also led this department, in the revision ofthe EDS necessary to implement Section 2-92-585, to change the ordinance's disjimctive in the reference to "any and all records ofthe [confracting] company or its predecessors" to a conjimctive in the EDS ("any and all records of

Hon. Edward M. Burke April 29, 2004 Page 3

the [contracting entity] and any and all predecessor entities").

Should you need additional assistance, please do not hesitate to contact

me.

Very truly yours,

inr-ojtji. A'/^^y^^^^

MARA S. GEORGES Corporation Counsel

3:. The jDisclosiiii; Party wil! subiiiit an iipdsitcd ceftiGcalion at the end of each calendar qun.ncrin W.hiclv there occurs any cyenttliat malehally uffects the accuracy bf the statements and iaformatioii set; forth-ijl pgnigraphs A. l , and A.2i above,

A. Thc-Disclpsing Party certifies that cither: (i) it is not an organizalion.dc.scribed in seclion 501.(c)(4) bfthc rntemal Rcveriiie;C6dc of 1986; or (ii) it is aii organization dcscribL-d.in seclion

. ,^ . i ,„ i_» . 1 t>.v r ^ A j f ihlo<c i . . - .. t ».,i,.i„„,i „„,( , , . ; M ,..^1 i . ; "T „i.t..:.'„.<.

Activities".

5. Tf the Di.";closiiig Party Is the' Applicant the p isclosing I'arly must obtaiirccriificiUions equal in form and subslaacc to paragraphs A. 1. througli A..4:. above from all subconlractors before it awartls .any subcoritfaiat: arid the.Disclosiiig Party mlisl mainlain all sijch subcpntiraclors' certifications.for the duration of the lyfattcr and most inakp-such cc'rtificatibn.s promptly available lo lhe Cily upoii request.

B. CERTIFICATION REG ARDTNC EQUAL EMPLOYMHINIT OPPORTUlsnTY

If the Matter is Fed.crally funded, federal regulations rcqiiirc the Applicant and .all proposed subcpnlnictbrs 10'submit ihc lbll6\v.ing information with their bids or in writing at tlic bulset.bf iiegptlatibns.

[& the pisc lqsing Party the Applicant?

[ ] Ves. l^No

If'*YcSj'' answerihtilirce questions bclpw;

\ . Hay.e yoU develbpcd and do. ybii have on file affirmaiive aciiovi progranisipursuant to applicable federal regulations? x'Sce 4,1 CiFR Pan 60-2.)

[•]Ycs: []W

.2. Have yoii filed with i:hc Ibiiit Reporting Committee, thp .Director of ibc Office of Federal Contract Gomplianco Programs, orrhe nqual Smpioymcnt Gpportnnity Commission all reports due iindcr the applicable filiiig requirements?

[}YeS []No.

.3.. llavcvyou'phrlicipatad in ariy.previous contracts or subcontracts subject to the equal opportunity clause?

H'Yes [ i N q

I f you clieclccd "No" tC! qiiesjion 1. pr 2. above, please provide an explanation:

i*agc.l0ori3

SECTION, v n AClkNoWLEDCiVlETs'TS, COTWTRAGT iNCORPGRATlON, CDMPLIANCE, PENALTllES, DISCLOSURli

Thc.pisclosing.PaTty understands and.agrees that:;

A. The ccriincation.';, di.sclosures, and acknowledgments contained in ihis.EDS wilfbceOmc parL ofany conlr2ct D.''d.thcr agrcciTient between the .Applicant and the City iti connection v.Mth.thc Matter,, whether prdcureniierit, City a-wisfancc, bf other Gilj'action, and aire mattirial indutciticnts to Uie Giiy's cxcciilioni of any contraci-or taking other action wjlh rcspcci to the Matter. The Bisclosing Patty undcr.stand.s that it must comply with all statutes, ordinahccs, ahcl regulations ort which this £DS"i's bascti.i

The City's:G.ovemriiental Elhics and Gainpaigh Financing.Ordinancd.Ss Chapters 2-156 and 2 .164 of -iho; Municipal Code, impose certain duties and obligaiiipns on persons.orrentilies seeking City contracts, work, business; or transactions. The f i i l l text of thiisc ordirianccs and a training jirograin is availabJc on­line at ww\v;crr^'ofchica^o,org/Ethic.s, and may also be.obtained from the City's IJoard ,of Ethics, 740 N".

Sedgwick'St/Suite.5i30,.Chicago, IL 60610, (31.2) 744-9660.. The Disclosing Party must cpmply fully with lhe applicable brdinahces:

G. I f the City detcrmiDCS Lhal any irifbnniitjQn provided in ihis nDS is falisc; iiicomplclc or iniiccuraic,. any contract or other agreement in connection, with which it i.<i .siibmitied may be resciiidcd or be void Or Voidable, aiiid the:City may piirsue aiiy remedies undor the cotitract or agirc-cmcnt ( i f not rescinded or Void), at law, Or in equity; including termiuaiing the Disclosing Pjirly's participatiojiin the Matter and/or declining to alToNv thb Disclosihg Party to p.articipaitc in. other transactionsSyith the City. Remedies at law for a false statement of nvatcrial fact may include incarceration and an award to. the City of trcbJc. dam ages.

D. It is the City's policy to make this document available to the public on its Intertibf site and/or tipori request SomcVor all pf thc information provided on Qn's EDS and any attachments'tp Ihis EDS in made available to ihc piiblic oh the Internet, iii response lb.a Freedom of iafoririatiqn.Act.rcqucStj oir. otherwise. By complctingiand signing this EDS, t]>c blsclosing Party waives and releases any possible right.s or claims which it may ha:vc!against Iho City in connection with the public rclca.sc of information contained in this EDS and also authorizes lhe City to verify Uic acciiracj^of any in fonnalion submiited in this EDS..

E/Thc inforrnation prbvidedin this EDS muist be kept current, in the event of changes, the Disclosing P.ariy raiist supplement.this EDS tip.io the time the Ci.iy iakcs.action on the Matter. I f tho-Matler is a cotitract being handled by the City's Departhierit of Pracurenienl Serv.ice.s, the Disclosing Party riiu.st Updaib this ED$. as the contract requires. fs'O.TE; With, respect to Matters subject to. Article I o f Chapter 1-23 of the Mtihicipal Codcdmposiiig PERiVfARENT iWELICi lBIUTY for qcriain specified: pffcnscs), the inforrnatiort provided hcrciq :regar4.ihg.ci}g)biiity m.ust:be kept current for a Ipirger period, a.s rcqiiired by Cliaplcr lr23 ihd Section 2.-154-020 df ihc Mnuicipal Code.

The Disclosing Party rcprcsbnts and warrants that:

Pagel! of 13

F. l . The Disclosing Party is not delinquent in tbe payment of any tax administered by the lUinois 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 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.

of Discio! (Print or type name

By:

sing Party)

(Sign here)

(Print or type name of peESOO'signing)

(Print or type title of person signing)

Signed and sworn to before me on (date) c , 20 I 3 ^"^^^ -elt^^v, 6SCUT: — (state).

Notary Public.

Commission expires: ^^O^^j 2 3 , ^ 6 I 3 •

Page 12 of 13

ViRQIKiAWILtlAMS Notary Public-No^ Seal

Stal9 of Missouri Commtesionad lor a Louis CRy

My Commission Expires: July 23,2013 Commisston Number 06841661

CITY OF CHICAGO ECONOiMlCDISCLOStJRE STATE

APPjENDIXA

F A M ] L L \ L RELATIONSHIPS WITH ELECTED CITY OFFICIALS AJND DEr'AimiE.N''r HCAJDS

This Appendix is to bc.comptctcij. only by (a).ihc Applicant, and (i>).any Icgjif entity which has a direct ownership interest in the Apph'cant cxitccding 7.5 percent. I f is. notfo be wmpletcd by any legal eiitity ivlijch has oiily an.indirect oSvneirship thfeircst in the Applicaut.

Under Municipal Code Seclion .2-154-01:3', the Disclosing Party must disclose wheiher such Disclosing Party or any .".Applicable.Party" or any Spou.se or Dqmc.'ttic Partner thereof currently has S 'Taritilial rclaiionship" with anyeicctcd city official or deparhncnt hcatl, A "familial rclitionship" exi.sts,il'. as ofthe ditlc this EDSis signed; tljc Disclosing Party or any "Applicable Party'".or any §pouse.or.D6inesiic Partner thereof is, related to the mayor, atiy aiderruaii,.uiC-.cily clerk, tiie city ircasur-cr'or any city dcpaitiTiciil.htad as spou'sp or clorncsiic partner or as iiny 6Cth(; folld\vi.ng, whether by blpod or'adoption;'parent, child, brother or Fistcr,. aunt or uncle, niece or ni^hew, grandparent, .grandchildj falhcr-in-law, mother-in-law, son-in-law, daugliicr-in-bw;.stepfather or.sf cpmother,. stepson, pr stepdaughter, stepbrother or stepsister pr halfbrotlier or half-sister.

"Appliciibie Party" means (j.) all cxccuttvc.'olTicers of the Disclosing Party listcd.in Section ILB. i .a., if tlic Disclosing Patly .is a cfirpbratioii; all parOiers' of the Disclosing Party, if tJic Disclosing Party is a.gener'a] partiiership; till general partDcrs and limited parfticre of theDisclosing Party, i f the Di.sclosing Party is iimifcd partnership;, all managers, managing members and.incmbcrsofihc D i ^ ^ i f the. Disclosing Party Is a lijnited liability cornpany; (2) all principal officcis oi" tlic Disclqsin^/Party; .ajid (3) any person having nriore than a 7.5 percent own.crsbip interest in the Disclosing Party, "Principal iifficcrs'" means the president, cWcf operating ofEccr, .executive director, chief financial officer; tfcasnrcr or sccretkty of i legal entity ^ ly person: e.xercising siijlilarautliorily..

Does the Disclosing Party or any "Applicable P.arty" or any Spbiisc-or E)omestic Pailner thereof currently, have a "^Tariiilial relationship'*'witli aji elected city official of dcpartriicht hciid? , v, > ^

[ ] YP. M No ' • ^ ^. / V ^ 1 T ,

I f yes, please identify beI6'\Y ()) the: nariic anti tidonf such person, (2) the name of the legal entity to which 'SUch;pcrs6n is connected; (3). the name and title oflh.c elected cityo'Hlciril or departmcht: head to \vhoin such person has a familial relationship, and (4:). the precise nature of such .famihal .relationship.

.Page: 13 of 13

(DO NOT SUBMIT THIS PAGE VVITH YOUR EDS. The purpose ofthis page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfiilly, the Disciosing Party must complete a new EDS with correct or corrected information)

RECERTIFICATIOiV

Generally, for use vvith City Council matters. Not for City procurements unless requested.

This recertification is being submitted in connection with / ^ i r > - fi'j(Jjr\n-iO ^Arfi^tL- cocAcT^ >4-r~ [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that / / / ^ t-Blsl-ilxP he/she is authorized to execute this EDS recertification on behalf ofthe Disclcsing Party, (2) fbfij^y £j)ifY warrants that all certifications and statements contained in the Disclosing Party's original EDS are true, accurate and complete as of the date fumished to the City and continue to be true, accurate and complete as ofthe date ofthis recertification, and (3) reaffirms its acknowledgments.

/y > 5 • ^ , AiMlf) hi/n- fISS ou. fUl bp (Print or type legal name of Disclosing Party)

Date 0 M i l By:

m. r (sign here)

Print or type name of signatory:

^erz^cp /y) . l<lJo^^

Title of signatory:

P

Signed and swom to before me on [date] <)C^ \rj j ) 1> ( Hh . i J . l/JL-^ " at <V . / fv . ' , ' s County,

j y ^ C ^ £ ^ 1 ^ - . K - ^ < ^ / g . Notary Public,

[state].

Commission expires: 11 y j j y I 7*

Vcr. H.01-05

KERI R TANKERSLEY Notary Public-Notary Seal

Stat* or Missouri. Saint Louis City . Comniisslon* 11210675

^^^^^ l ^^n^ f i i tes l iov22 2015

C I T Y OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTIOiN 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:

U.S. Bancorp

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is: 1. [ ] 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. [x] 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: U-S. Bank, N.A.

B. Business address of the Disclosing Party: 800 Nicollet Mall

Minneapolis, MN 55402

C. Telephone: (314) 335-2560 Fax: (314) 335-2568 Email: nnatthew.potter(S)usbank.conn

D. Name of contact person: Matthew/ w. Potter

E. Federal Employer Identification No. (if you have one):

F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Subdivision of land located at l l l t h and Bishop Ford Expressway

ent ,1,1 • 1 ] * . • »• tu- r r^co Department of Housing and Economic Developm G. Which City agency or department is requesting this EDS?

Department of Transportation

I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following:

Specification # and Contract #

Ver. 01-01-12 Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person [ ] Limited 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 P<] No [ ] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

I . List below the full names and titles of all executive officers and all directors ofthe entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

I f the entity is a general partnership, limited partnership, limited liability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title See attached.

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

04/15/2013

U.S. Bancorp

Name;.'; '/.•..'.•:•'.:'• Title - j - i r - i O ^ i ^ ^ C - i ' ^ . ; - " ' . v - ; £ - r : K : . :•' ri-'•••::'::•;<-•: Davis, Richard K. Director, Chairman of the Board

Baker, Douglas M. Jr Director

Belton, Y. Marc Director

Buyniski Gluckman, Victoria Director

Collins, Arthur D. Jr. Director

Hernandez. Roland A. Director

Johnson, Joel W. Director

Kirtley, Olivia F. Director

Levin, Jerry \N. Director

O'Maley, David B. Director

Ow/ens, O'dell M. Director

Schnuck, Craig D. Director

Slokes, Patrick T. Director

Woo Ho. Doreen Director

Davis, Richard K. Chairman, President, and CEO

Carlson, Jennie P. Executive Vice President

Chosy, James L. Executive Vice President. General Counsel and Secretary

Gifford, Craig E. Executive Vice President and Controller

Griffith, Kenneth (Randy) Executive Vice President

Hidy, Richard J. Executive Vice President and Chief Risk Officer

McCullough, HovjeW D. (Mac) III Executive Vice President and Chief Strategy Officer

Nelson, Kenneth D. Executive Vice President and Treasurer

Oldshue, Paul F. Executive Vice President

Parker, P.W. (Bill) Executive Vice President and Chief Credit Officer

Somers, Timothy W. Executive Vice President

Cecere, Andrev/ Vice Chairman andChief Financial Officer

Dolan, Terrance R. Vice Chairman

Elmore, John R. Vice Chainnan

Hoesley, Joseph C. Vice Chainman

Joseph, Pamela A. Vice Chairman

Payne, Richard B. Jr. Vice Chairman

Stone, Kent V. Vice Chairman

von Gillern, Jeffry H. Vice Chairman

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

Name Business Address Percentage Interest in the Disclosing Party

None

SECTION III -- BUSINESS RELATIONSHIPS VVITH 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 Y e s [x] N o To the best of our knowledge, after due inquiry

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

SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

I f the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13

Name (indicate whether Business Relationship to Disclosing Parly Fees (indicate whether retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE: to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is

not an acceptable response.

(Add sheets i f necessary)

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

SECTION V -- C E R T I F I C A T I O N S

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

[ ] Yes [ ] No [x] No person directly or indirectly owns 10% or more of the Disclosing Party.

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

[JYes [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 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, 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. 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. ofthis Section V;

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

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

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

• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a public officer or employee of the City, the State of Illinois, or any agency of the federal government or ofany state or local government in the United States of America, in that officer's or employee's official capacity;

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

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

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

4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of ( I ) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or 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:

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 anytime during the 12-month 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").

None known

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 ofthe City recipient.

None known

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ J is [ ^ is not

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

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

"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 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 ofits 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):

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 v/ith Section 2-156-110 ofthe Municipal Code: Does any official or ei-nployee of the City have a financial interest in his or her own name or in the name ofany other person or entity in the Matter?

[ ] Yes PJ N o T° ^^^^ °^ knowledge, after due inquiry

NOTE: I fyou 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 pursuani to a process of competitive bidding, or otlierwise perniitted, 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 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 certitles 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.

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.

y 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: U.S. Bancorp was founded after the slavery era, so it would not have any disclosure statement separate from that of its subsidiary,

U.S. Bank National Association. It has no separate assets or activities that predate the 20th Century.

SECTION VI - C E R T I F I C A T I O N S FOR F E D E R A L L Y FUNDED MAT I 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 VIL 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. 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 agreement.

Page 9 of 13

Attachment A

City of Chicago Economic Disclosure Statement and Affidavit

Statement Regarding Slavery Era Business

U.S. Bank National Association was formed from the following major banks: (1) Star Bank, National Association (Cincinnati, Ohio) changed its name to Firstar Bank, National Association (Cincinnati, Ohio) effective February 1999; (2) Mercantile Bank National Association (St. Louis, Missouri) merged into Firstar Bank, National Association (Cincinnati, Ohio) effective April 2000; (3) United States National Bank of Oregon (Portland, Oregon) merged with First Bank, National Association under the title U.S. Bank National Association effective August 1997; (4) U.S. Bank National Association merged into Firstar Bank, National Association, and the succeeding bank, changed its name lo U.S. Bank National Association effective August 2001. These banks acquired through mergers and acquisitions numerous smaller banks. There are five hundred and forty-two U.S. Bank National Association predecessors. Thirty-five predecessors were founded before the abolition of slavery in December 1865. Thirteen of the pre-1866 predecessors were established in southern slave-holding states and territories, including Kansas, Kentucky, Missouri, and Tennessee.

In reviewing historical records held in various external repositories in accordance with the research requirements as set forth in the City of Chicago Office of the Corporation Counsel opinion letter dated April 29, 2004 (attached hereto), U.S. Bank National Association has identified external records of its predecessors which necessitate disclosure. The conveyance records, while showing no record of direct ownership of enslaved individuals did contain records of founders and/or directors of predecessor banks owning enslaved individuals, as well as a record where an enslaved individual was the collateral for a loan. Specifically, the first president of predecessor Marion National Bank of Lebanon, Kentucky (founded in 1856), Benedict Spalding, owned two enslaved individuals in 1850. In 1860 someone with a similar name "Benidict Spalding" is also listed as having owned fourteen enslaved individuals. In addition, certain members of the Marion National Bank of Lebanon's board of directors (called "commissioners") owned approximately forty-seven enslaved individuals in total (the records include abbreviated names, which we conclude may be references to commissioners). The first president of predecessor First National Bank of Clarksville, Tennessee (founded in 1865), S.F. Beaumont, owned one enslaved individual in 1860. The first president of predecessor St. Louis Building and Savings Association, Missouri (formed in 1857), Marshall Brotherton, owned ten enslaved individuals in 1850 and four enslaved individuals in 1860. Merchants Bank (founded in 1857) and Bank of St. Louis (founded in 1857), both predecessors, along with a group of other St. Louis firms, issued a mortgage to Charles McLaran that was secured by his property, which included an unspecified number of enslaved individuals. However, the 1860 Federal Census Slave Schedule for St. Louis provided that Charles McLaran owned thirteen enslaved individuals.

The above is only a summary. U.S. Bank National Association has previously provided the City of Chicago with supporting attachments.

U.S. Bancorp, the parent company of U.S. Bank National Association, was founded after the slavery era and has no separate assets or activities that pre-date the 20th century. As such, it has no disclosure separate from that of the bank.

Citj'of Chicago Richard M. Daley, Mayor

Deparlmenl ofLaw

Mara S. Georges Corporation Counsel

Cily Hall, Room 600 121 North LaSalle Streel Chicago, IlliDois 60602 (312) 744-6900 (312) 744-8538 (FAX) (312) 744-2963 (TrY)

litlp://www.ci.chi.il.us

April 29, 2004

Hon. Edward M. Burke Chairman, City Council Committee on Finance City Hall, Room .• 02 121 North La Salle Street Chicago Illinois 60602

Re: Question regarding Economic Disclosure Statement and Affidavit, Part VI ("Certification Regarding Slavery Era Business") and Resolution pending before the Joint Committee on Finance and Human Relations

Dear Alderman Burke:

In a letter dated April 26, 2004, you indicated that a special committee of the City Council, consisting of the combined Committee on Finance and the Committee on Human Relations, currently has under consideration a resolution that raises certain issues regarding interpretation of Section 2-92-585 of the Chicago Municipal Code, the Business, Corporate and Slavery Era Insurance Ordinance. That ordinance requires every city contractor to "complete an affidavit verifying that the contractor has searched any and all records of the company or any predecessor company regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era. The names of any slaves or slaveholders described in those records must be disclosed in the affidavit." (Emphasis supplied)

The affidavit requirement of Section 2-92-585 has been incorporated into the standard Economic Disclosure Statement ("EDS") completed by city contractors as Part VI, entitled "Slavery Certification." The EDS requires an entity contracting with the city to verify that it has "searched any and all records of the Undersigned and any and all predecessor entities for records of investments or profits from slavery, the slave industry, or shareholder insurance policies." (Emphasis supplied) The EDS form then requires the contracting entity to disclose the results of that search.

You have asked specifically whether it is "reasonable to interpret the language 'records of the undersigned and any and all predecessor entities' to mean [the contracting entity's] records and the records ofits predecessor entities." For the rea.sons that follow, it is the opinion ofthis office that the answer is in the

Hon. Edward M. Burke April 29, 2004 Page 2

affirmative. A search required for proper compliance with and disclosure under Section 2-92-585 must include all known records of the contracting entity and each ofits predecessor entities, to which records the contracting entity has or can obtain access.

Neither the ordinance nor any Illinois decision defines a "predecessor" entity of a city contractor. Under the general ndes of statutory construction, the word should be given its ordinary meaning. Black's Law Dictionary defines "predecessor" as "one who goes or has gone before; the correlative of 'successor' Applied to a body politic or corporate, in the same sense as 'ancestor' is applied to a natural person." This simple analogy indicates that every known antecedent entity of a city contractor - acquired entides, components of earlier mergers, entities acquired by and subsumed into a prior entity that became a predecessor of a contracting entity - should be treated as a predecessor. This is especially appropriate when one considers the preamble to the ordinance adding Section 2-92-385 to the Chicago Municipal Code. The fifth paragraph ofthe preamble (found at page 94891 of the Joumal of Proceedings of the City Council of October 2, 2002) refers to records located in the archives of current insurance firms, documenting slave insurance policies "issued by a predecessor insurance firm; the sixth paragraph (id.) refers to "insurers and businesses whose successors remain in existence today." Thus the City Council recognized that, as the American economy has expanded and become more complex, modern business may include different business disciplines (insurers and other businesses).

The appropriate extent of the mandated records search can also be discerned fi-om the preamble. The final paragraph ofthe preamble (p. 91892) contains a finding ofthe City Council that entities "doing business with the City of Chicago shall take any and all steps in good faith to disclose any records within their possession or knowledge relating to investments or profits from the slave indu.stry including insurance policies...." (Emphasis supplied) In order to implement this statement ofthe Council's intent, a contracting entity may not ignore records that are archived outside the entity's possession {e.g. in a museum, university library, historical society or trade association). To ignore deliberately the existence of such known records could not possible constitute a "good faith" effort to take "any and all steps" to document the contractor's history. The breadth of the City Council's desired disclosure also led this department, in the revision ofthe EDS necessary to implement Section 2-92-585, to change the ordinance's di!;junctive in the reference to "any and all records ofthe [contracting] company or its predecessors" to a conjunctive in the EDS ("any and all records of

Hon. Edward M. Burke April 29, 2004 Pages

the [contracfing entity] and any and all predecessor entities").

Should you need additional assistance, please do not hesitate to contact

me.

Very tmly yours,

MARA S. GEORGES Corporation Counsel

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) 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 Activities".

5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[ ] Yes [X] No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

[ ] Y e s [ ] N o

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ j Y e s [ ] N o

3. Have you participated in any previous contracts or subcontracts subject to the equal opportunity clause?

[ ]Yes [ ] N o

If you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13

SECTION VII - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, C O M P L I A N C E , P E N A L T I E S , DISCLOSURE

The Disclosing Party understands and agrees that:

A. The cerlifications, disclosures, and acknowledgments contained in this EDS will become part ofany contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the applicable ordinances.

C. 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 ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current, in the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F.l . The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities dehnquent in paying any fine, fee, tax or other charge owed to the City. TTiis 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 Apphcant, 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") maiiitamed bythe u . S. General Seivices AdmiinstiaLiori.

F.3 I f the Disclosing Party is the Apphcant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired iu conuection 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 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 taie, accurate and complete as ofthe date fumished to the City.

of Dirolos: (Print or type name of Dirolosing Party)

(Print or type name of person signing)

4vr (Print or type title of person signing)

Signed and swom to before me on (date) (ZU/^uyt l ^ c L P I 3 ^

at IteywtpVvv County, _f4ivvv5*>iS^ (state).

<^^jdliCUv-t. (^r ^ l^^^v^^^fcr Notary Public.

Commission expires: QU?*! ( li-^

Page 12 of 13

f ^ ^ ^ •llJl"*NABfiANWOjtJNQUE)IMPANEnA i ^ ^ l 'NOTARYPUBLIC-MINNESOTA ^ L ^ ^ My Commission Expires Jan. 31,2017 I

CITY OFCHICACO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof cun ently 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, niccc or nephew, grandparent, grandchild, fathcr-in-lavv', mother-in-lavv', son-in-luvv', 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., 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.

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

[ ] Yes ] N o To the best of our knowledge, after due Inquiry

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 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

(DO NOT SUBMIT THIS PAGE WITH YOUR EDS. The purpose ofthis page is for you to recertify your EDS prior to submission to City Council or on the date of closing. If unable to recertify truthfiilly, the Disclosing Party must complete a new EDS with correct or conrected information)

RECERTIFICATION

Generally, for use with City Council matters. Not for City procurements unless requested. AMUjDii ifjT •r> Pt>itun f su&nivisfot dP

This recertification is being submitted in connection with / " P/)//JV\MO ffTAtL- cjoCArVc ' AT~ [identify the Matter]. Under penalty of perjury, the person signing below: (1) warrants that / / / ^ 't-Bl^titP he/she is authorized to execute this EDS recertification on behalf of the Disclosing Party, (2) f6fij:> & y . f ^ warrants that ail certifications and statements contained in the Disclosing Party's original EDS arc true, accurate and complete as of the date fumished to the City and continue to be true, accurate and complete as of the date of this recertification, and (3) reaffirms its acknowledgments.

0Bnr^c^i^r (Print or type legal name of Disclosing Party)

Date: 10,

,y<i [rAr^'dUX--(sigirnerc) \

Print or type name of signatory:

Title of signatory:

^

Signed and swom to before me on [date] Q c ^ ^ ^ < ^ t ^ i-tMJfc\ f . ^edrxiUlHi ,at tjgvwc^ County,

_ Notary Public.

Commission expires: O

[state].

Vcr. 11-01-05

JUUANA BRANCATO JUNQUEIRA PANETTA (3 NOTARY PUBLIC - MINNESOTA

' My Commission Expires Jan. 31,2017 |