Jahn Design Proposal

City of Chicago

Office Of the City Clerk

Document Tracl<ing Sheet

02015-6394

Meeting Date:

Sponsor(s):

Type:

Title:

Committee(s) Assignment:

9/24/2015

Misc. Transmittal

Ordinance

Zoning Reclassification Map No. 4-E at 920-1006 S Michigan Ave and 1011-1015 S Wabash Ave - App No. 18503 Committee on Zoning, Landmarks and Building Standards

ORDINANCE

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

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

Ordinance, be amended by changing all the DX-12 and DX-16 Downtown Mixed Use

District symbols and indications as shown on Map No. 4-E in the area bounded by:

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

to the designation of DX-16 Downtown Mixed Use District and a corresponding use

district is hereby established in the area above described.

SECTION 2: That Title 17 of the Municipal Code of Chicago, Chicago Zoning

Ordinance, be amended by changing all the DX-16 Downtown Mixed Use District

symbols and indications as shown on Map No. 4-E in the area bounded by:

th

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

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

established in the area above described, subject to such use and bulk regulations as are

set forth in the Plan of Development attached herewith and made a part thereof and to

no others.

SECTION 3: This ordinance shall take effect upon its passage and due publication.

PLANNED DEVELOPMENT STATEMENTS

1. The area delineated herein as Residential Business Planned Development Number , ("Planned Developmenf) consists of approximately 46,287 square feet of property which is depicted on the attached Plarmed Development Boundary and Properly Line Map ("Property") and is owned, controlled or zoning consent has been received by the Applicant, 1000 South Michigan Equifies, LLC.

2. The requirements, obligations and conditions contained within this Planned Development shall be binding upon the Applicant, its successors and assigns and, if different than the Applicant, the legal title holders and any ground lessors. All rights granted hereunder to the Applicant shall inure to the benefit of the Applicant's successors and assigns and, if different than the Applicant, the legal title holder and any ground lessors. Furthermore, pursuant to the requirements of Section 17-8-0400 of the Chicago Zoning Ordinance, the Property, at the time of application for amendments, modifications or changes (administrative, legislative or otherwise) to this Planned Development are made, shall be under single ownership or designated control. Single designated control is defined in Section 17-8-0400 of the Zoning Ordinance.

3. All applicable official reviews, approvals or permits are required to be obtained by the Applicant or its successors, assignees or grantees. Any dedication or vacation of streets or alleys or grants of easements or any adjustment of the right-of-way shall require a separate submittal to the Department of Transportation on behalf of the Applicant or its successors, assign or grantees. Any requests for grants of privilege, or any items encroaching on the public way, shall be in compliance with the Plans.

Ingress or egress shall be pursuant to the Plans and may be subject to the review and approval of the Departments of Planning and Development and Transportafion. Closure of all or any public street or alley during demolition or construcfion shall be subject to the review and approval of the Department of Transportafion.

All work proposed in the public way must be designed and constructed in accordance with the Department of Transportation Construction Standards for Work in the Public Way and in compliance with the Municipal Code of the City of Chicago. Prior to the issuance of any Part II approval, the submitted plans must be approved by the Department of Transportation.

4. This Plan of Development consists of 15 Statements: a Bulk Regulafions Table; an Existing Zoning Map; an Existing Land-Use Map; a Plarmed Development Boundary and Property Line and Sub-Area Map; Site Plan / Ground Floor Plan; Green Roof and Landscape Plan; Building Secfion Plan; and Building Elevations (North, South, East and West) prepared by Jahn Architecture and dated September 24, 2015, submitted herein. Full-sized copies of the Site Plan, Landscape Plan and Building Elevations are on file with the Department of Planning and Development. In any instance where a provision of this Planned Development conflicts with the Chicago Building Code, the Building Code shall control. This Planned Development conforms to the intent and purpose of the Zoning Ordinance, and all

AppliciUit. 1000 SOUTH MICHIGAN EQUITIES, LLC Address. 920-1006S MICHIGAN AVE.. 1011-I0I5 S. WABASH AVE. introduced. September 24, 2015 Plan Commission. TBD

1

requirements thereto, and satisfies the established criteria for approval as a Plarmed Development. In case of a conflict between the terms of this Planned Development Ordinance and the Zoning Ordinance, this Planned Development Ordinance shall control.

5. The following uses are permitted in the area delineated herein as a Residential Business Planned Development. In each of the following Sub Areas, the following uses shall be permitted in this Plarmed Development:

Sub-Area A: residential uses, including up to 506 dwelling units, commercial uses, general retail sales, eating and drinking establishments, liquor sales as an incidental use, accessory parking, of which 45% of the required residential parking (maximum 264 spaces) may be leased out on a daily, weekly or monthly basis to persons who are not residents, tenants, patrons, employees or guests of the principal uses, co-location of wireless telecommunication and satellite facilities, related facilities and accessory uses.

Sub-Area B: office, commercial uses, general retail sales, school, college, universities, day care, eating and drinking establishments, liquor sales as an incidental use, accessory parking, co-location of wireless telecommunication and satellite facilities, related facilities and accessory uses.

6. On-Premise signs and temporary signs, such as construction and marketing signs, shall be permitted within the Planned Development, subject to the review and approval of the Department of Planning and Development. Off-Premise signs are prohibited within the boundary of the Planned Development.

7. For purposes of height measurement, the definitions in the Zoning Ordinance shall apply. The height of any building shall also be subject to height limitations, i f any, established by the Federal Aviation Administration.

8. The maximum permitted Floor Area Ratio ("FAR") for the site shall be in accordance with the attached Bulk Regulations Table. For the purposes of FAR calculations and measurements, the definitions in the Zoning Ordinance shall apply. The permitted Floor Area Ratio identified in the Bulk Regulations Table has been determined using a Net Site Area of 46,287 square feet and a base FAR of 16.00. The improvements to be constructed on the Property will utilize the following series of FAR bonuses:

Description (list of all bonuses applied for and calculations) FAR

Base FAR: 16.00 Concealed Parking Fafade 2.02 Setback Bonus 2.45 Green Roof Bonus 1.03 Affordable Housing Bonus 1.37 Total FAR: . 22.87

Applicant 1000 SOUTH MICHIGAN EQUITIES. LLC Address: 920-1006 S. MICHIGAN AVE., 1011-1015 S. WABASH AVE. Introduced. September 24, 2015 Plan Commission TBD

9. Upon review and determination, "Part II Review", pursuant to Section 17-13-0610 of the Zoning Ordinance, a Part II Review Fee shall be assessed by the Department of Planning and Development. The fee, as determined by staff at the time, is final and binding on the Applicant and must be paid to the Department of Revenue prior to the issuance of any Part II approval.

10. The Site and Landscape Plans shall be in substantial conformance with the Landscape Ordinance and any other corresponding regulations and guidelines. Final landscape plan review and approval will be by the Department of Plaiming and Development. Any interim reviews associated with site plan review or Part II reviews, are conditional until final Part II approval.

11. The Applicant shall comply with Rules and Regulations for the Maintenance of Stockpiles promulgated by the Commissioners of the Departments of Streets and Sanitation, Envirormient and Buildings, under Section 13-32-125 of the Municipal Code, or any other provision of that Code.

12. The terms and conditions of development under this Planned Development ordinance may be modified administratively, pursuant to section 17-13-0611-A ofthe Zoning Ordinance by the Zoning Administrator upon the application for such a modification by the Applicant, its successors and assigns and, i f different than the Applicant, the legal title holders and any ground lessors.

13. The Applicant acknowledges that it is in the public interest to design, construct and maintain the project in a manner which promotes, enables and maximizes universal access throughout the Property. Plans for all buildings and improvements on the Property shall be reviewed and approved by the Mayor's Office for People with Disabilities to ensure compliance with all applicable laws and regulations related to access for persons with disabilities and to promote the highest standard of accessibility.

14. The Applicant acknowledges that it is in the public interest to design, construct, renovate and maintain all buildings in a manner that provides healthier indoor environments, reduces operating costs and conserves energy and natural resources. At the time of a hearing before the Chicago Plan Commission, all developments must be in substantial compliance with the current City of Chicago Sustainable Development Policy set forth by the Housing and Economic Development. The proposed Plarmed Development shall be in compliance with the Sustainable Development Policy by obtaining LEED certification and by providing a green roof of at least 50% of Net Roof Area of the new buildings constructed in Sub-Area A containing a green roof of 22,961 square feet and shall meet the applicable storm water requirements of the Department of Planning and Development.

15. This Planned Development shall be governed by Section 17-13-0612 of the Zoning Ordinance. Should this Planned Development ordinance lapse, the Commissioner of the Department of Planning and Development shall initiate a Zoning Map Amendment to rezone the property to the DX-16 Downtown Mixed Use District.

Applicant: 1000 SOUTH MICHIGAN EQUITIES, LLC Address- 920-1006 S. MICHIGAN AVE., 1011-10I5 S. WABASH AVE. Introduced- September 24, 2015 Plan Commission TBD

3

1000 S. Michigan - S. Michigan Avenue | 11th Street | S. Wabash Avenue | 9th Street

PLANNED DEVELOPMENT

BULK REGULATIONS AND DATA TABLE

Sub Area A

1000 S. Michigan

Sub Area B

1006 S. Michigan &

S. Wabash Parcel

Total

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

41,884 SF 21,388 SF 63,272 SF

Area in Public Right-of-Way

9,545 SF 7,440 SF 16,985 SF

Net Site Area 32,339 SF 13,948 SF 46,287 SF

Maximum Floor Area

Ratio 30.29 5.66 22.87

FAR Area 979,497 SF 78,881 SF (existing)

1,058,378 SF

Maximum Number of Residential Units

506 0 0

Number of Off-Street Parking Spaces Provided

586 1 2 (existing) 598

Number of Off-Street Loading Docks

3 1 (existing) 4

Minimum Building

Setbacks As per Site Plan None (existing) -

Maximum Building Heigfit

993' 102' (existing) -

Green Features LEED Certified +

Green Roof None -

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

JAHN

EXISTING ZONING MAP SCALE: r=120'-0"

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

JAHN COPYRIGHT O JAW. LLC 2015

ALL RIGHTS RESERVED

45 90 135 180

EXISTING LAND USE MAP SCALE: 1"=18ff-0"

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

JAHN

99-4" 36'

-EXBTINB Iff PUatre-AttEY

.1- : S. WABASH AVE.

EXISHNG SURFACE PARKING LOT

-EXISrMtf-PUBUe-AHBf*^ •

DdSTING 20 STORT RESIDENTIAL BUILDING

134-3 3/8"

SITE SUHMART SUB K

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

41.884 SF 9,545 SF 32.339 SF

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

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

TOTAL NET AREA = (NET AREAS A+B)

46.287 SF

PLANNED DEVELOPMENT BOUNDARY, PROPERTY LINE AND SUB AREA MAP

15 30 45 60

SCALE- r=60'-0'

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

JAHN

S. WABASH AVE.

0£.

o p Qy 09) o o

o EXISTING

PARK

10 PUBLIC ALLEY

SURFACE "PARKING

LOI FOR JIQ06 S. MICHIGAN

(W-SPCSl

EXISTING SURFACE PARKING LOT

11l'-8" 2-3 5/8"

20'-2 3/8" ^

-V

COLUMBIA COLLEGE GETZ THEATER

10' PUBLIC ALLf

COLUMBIA COLLEGE

1014 S. MICHIGAN

EXISTING 8-STORY BUILDING

1006 S. MICHIGAN

EASEMENT 4 PAVED VEHICULAR ACCESS

MICHIGAN AVE.

t i LLJ CH CO

EXISTING 19-STORY BUILDING

PROPOSED PUBLIC ART - SEE NOTE #1

900 S. MICHIGAN

NOTE: 1. PUBLIC ART SHALL BE PERMITTED BUT NOT REQUIRED. SELECTION OF PIECE AS WELL AS

THE ACQUISITION COST SHALL BE THE RESPONSIBILITY OF THE APPLICANT.

SITE PLAN / GROUND FLOOR PLAN 0 15 30 45 60

SCALE: 1"=60'<l"


JAHN

S. WABASH AVE.

oj lo —EXIST. rSURFACE

o o EXISTING

PARK

10' PUBLIC ALLEY

PARKING LOT

oc

COLUMBIA COLLEGE GETZ THEATER

EXISTING 4 7 STORV

10' PUBLIC ALLEY

COLUMBIA COLLEGE

EXISTING 4-STORY

EXISTING SURFACE PARKING LOT

B-STORT

1014 s. MICHIGAN

1006 S. MICHIGAN 1000 S. MICHIGAN

AREAS: ). ROOFTOP GARDEN: 2. HARDSCAPE: 3. GREEN ROOF:

MECH. GREEN ROOF: MECH. GREEN ROOF: ROOF TERRACE: GREEN ROOF:

8. MECHANICAL

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

19-STORY ±2flLQl

0£.

CD

900 S. MICHIGAN

S. MICHIGAN AVE.

GREEN ROOF CALCULATION A TOTAL ROOF AREA = SUM (1-9) B l£SS ROOF MECHANICAL AREA •> -(8+9) C TOTAL NET ROOF AREA = SUM (1-7) D REQUIRED GREEN ROOF AREA (SOX OF NET ROOF) E TOTAL GREEN ROOF PROVIDED = 1+3+4+5+7 F TOTAL GREEN ROOF IN EXCESS OF 50% NET ROOF G FAR. BONUS = 9.902.7 / 46,287 X 0.30 X 16

(E-D)

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

1.0269 BONUS: 47,532 SF

GREEN ROOF AND LANDSCAPE PLAN 15 30 45 60

SCALE r=60'-0-


JAHN

gg3'_0" UNDERSIDE OF UPPERMOST

OCCUPIED FLOOR l i U j . L i u

LQJJ

w m in

m m m l j U j , i U L t

m HI m

m w m

lUUL ijJLa

ULUL ULQJl

l i L U

i l L U

mmifi

m j u , n ID in

i l lLU

ROOFTOP GARDEN 128'-0"

\

3;

SL 1030'-2"

76B'-0''

CONDO 20 FLOORS © 11-6" AFF +1 FLOOR © 15'-0" AFF

523' -0 '

CONDO 20 FLOORS © 11-6" AFF +1 FLOOR © 15*-0" AFF

278'-0"

248' -0 '

148'-0"

128'-0"

n ra

^ 9&V-0' 9, A 979'-6"

UNDERSIDE OF UPPERMOST RESIDENTIAL FLOOR SUB

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

ROOF TERRACE

APARTMENTS ° 11 FLOORS © 10'-0" AFF "g

PARKING / APARTMENTS o 9 FLOORS © lO'-O" AFF -J, +1 FLOOR © 13-0" AFF 2

V7 25'-0"

"o CONDO AMENITIES

1 1 FLOOR SHARED AMENITIES

4 ^ LOBBY / RETAIL

S. WABASH AVE. S. MICHIGAN AVE.

BUILDING SECTION SCALE: 1"=110'


JAHN

k/AxllluH HEIGHT

GLASS SCREEN WALL

EXISTING 4 STORY AND EXISTING 8 STORY OFFICE BUILDING COLUMBIA COLLEGE 1014 AND 1006 s, MICHIGAN AVE,

BALCONIES WITH GLASS RAILS

EXISTING 20 STORY RESIDENTIAL BUILDING 910 AND 900 s. MICHIGAN AVE.

nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn TOW

nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn

• • • • • • • •

• • •• on no

PROPOSED PUBLIC ART

11 TH ST. 9TH ST,

EAST ELEVATION - SOUTH MICHIGAN AVENUE SCALE: 1"=B0'

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

JAHN

EXISTING 20 STORY RESIDENTIAL BUILDING 910 AND 900 s. MICHIGAN AVE. - BEYOND

EXISTING 4 AND 7 STORY BUILDING—•-

COLUMBIA COLLEGE 62 E. 1ITH ST.

D 0 D H 0 0 D B D B 0 B 0 B D B

rmrmm rmnxirTT ID rnifrnrn nmrmrn rmnxirn

B BBBBBBBBBB B

Q Q Q Q B Q Q

[pi] o o o o o [p]

1 OD 00 00 00 DD DO DO 00 DD 00 00

00

rTTT TTT TIT TTT TTT TTT TTT

• GLASS SCREEN WALL"

- CLASS FACADE-

GUSS FACADE-

GLASS FACADE-

BALCONIES WITH GLASS RAILS

TRANSLUCENT CLASS FACADE

-8 AND 4 STORY EXISTING OFFICE BUILDING COLUMBIA COLLEGE 1006 s. MICHIGAN AVE.

PROPOSED PUBLIC ART

3T

CONCRETE/ y ^ CONCRETE - /

/ BLOCK PARTY WALL

WABASH AVE. S. MICHIGAN AVE.

SOUTH ELEVATION - EAST 11TH STREET ELEVATION BEYOND

SCALE: 1"=110'

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

JAHN

GLASS SCREEN WALL"

EXISTING 20 STORY RESIDENTIAL BUILDING —

910 AND 900 s. MICHIGAN AVE.

—innnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn nnnnnnnn

nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn nnnn

i

i

i

-GLASS FACADE

-BALCONIES WITH GLASS RAILS

-GLASS FACADE

CLASS FAaOE EXISTING 8 STORY OFFICE

-• BUILDING COLUMBIA COLLEGE ' 1006 s. MICHIGAN AVE. - BEYOND

EXISTING 4 AND 7 - STORY BUILDING

COLUMBIA COLLEGE 62 E. 11TH ST.

9TH ST. WEST ELEVATION

11 TH ST. SOUTH WABASH AVENUE SCALE: 1"=110'

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

JAHN

GLASS SCREEN WALL"

-GLASS FACADE r—TRANSLUCENT GLASS FACADE

PROPOSED-PUBLIC ART

ELEVATION BEYOND J

-GLASS FACADE

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

nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn nnnnnnnnnnnnnnnnnnnn • • ! • • • a • • • DII • • I l i a • • • IID • • •

• • ! a u • • • DJ • •Ilia • • • | D • • •

m o o STMICHIGAN AVE.

NORTH ELEVATION - EAST 9TH STREET S. WABASH AVE

SCALE: 1"=110'


JAHN

Schuyler Roche

Crisham

S c H L i - i L E R , R L J D H I ; ; & C R I S H A M , P . C

ATTORNEYS Two Prudctitial Plaza 180 North Stetson Avenue Suite 3700 Chicago, Illinois 60601

312.565.2400 TEL. 312.565.8300 FAX SRCatiorueys.com

J O H N J . G E O R G E

Attorney at Law TEL 312 565.8439 FAX 312 565.8300 JGeorqe(S)SRCattornevs.com

September 15, 2015

USPS FIRST CLASS MAIL

In re:

Dear Property Owner:

Zoning Amendment and Lakefront Protection Application 920-1006 S. Michigan Ave. and 1011-1015 S. Wabash Ave. Chicago, Illinois

In accordance with the requirements for an Amendment to the Chicago Zoning Ordinance and for an approval under the Lake Michigan and Chicago Lakefront Protection Ordinance, please be informed that on or about September 15, 2015, I, the undersigned attorney, will file an Application for a change in zoning from DX-12 and DX-16 Downtown Mixed Use District to the DX-16 Downtown Mixed Use District and then to a Residential-Business Planned Development and for approval under the Chicago Lakefront Protection Ordinance on behalf of the Applicant for the property located at 920-1006 S. Michigan Ave. and 1011-1015 S. Wabash Ave., Chicago, liiinois and bounded by a line 134.28 feet south of and parallel to East 9th Street; South Michigan Avenue; a line 56.07 feet north of and parallel to East 11th Street; the alley next west of and parallel to South Michigan Avenue, the alley next north of and parallel to East 11th Street, the alley next east of and parallel to South Wabash Avenue, a line 99.33 feet north of and parallel to East 11th Street; South Wabash Avenue; a line 135.40 feet north of and parallel to East 11th Street; a line 240.94 feet west of and parallel to South Michigan Avenue.

The purpose of the proposed zoning amendment and proposed Chicago Lakefront Protection Ordinance approval is to permit the construction of 86 story residential tower building with a height of 993' containing 506 dwelling units, ground floor retail space and 598 accessory parking spaces with the existing office building to remain.

The Applicant is 1000 South Michigan Equities LLC, whose business address is 55 Fifth Avenue, New York, New York, 10003. The owners of the property are listed on the reverse side of this letter.

I am the attorney for the Applicant. My address is Schuyler, Roche & Crisham, P.C, 180 N. Stetson Avenue, Suite 3700, Chicago, Illinois 60601. Please feel free to contact me at (312) 565-8439 if you should have any questions concerning the Application.

Please note that the Applicant is not seeking to purchase or rezone your property. The Applicant is required by law to send you this notice because you own property located within 250 feet of the proposed development.

Very Truly Yours,

/ / John J. George

SUB-AREA A:

First American Bank, not personally, but as trustee U/T/A dated April 6, 2009 and known as Trust number 1-09-111 218 West Main Street West Dundee, IL 60176 Contact: Dawn Griffin 847-403-8109 [email protected]

SUB-AREA B TENANTS IN COMMON OWNERS:

33'''' Street 1006 Michigan LLC 55 Fifth Avenue, 15"" Floor New York, New York, 10003 Contact: Robert Singer 212-206-6097 [email protected]

131 West 33'" 1006 Michigan Avenue, LLC 55 Fifth Avenue, 15"" Floor New York, New York, 10003 Contact: Robert Singer 212-206-6097 [email protected]

RK 2011 Trust 1006 Michigan Avenue LLC 55 Fifth Avenue, 15' Floor New York, New York, 10003 Contact: Robert Singer 212-206-6097 [email protected]

1006 S Michigan LLC 2 Seaview Blvd. Port Washington, NY 11050 Contact: Jordan Karlik 516-622-7500 [email protected]

September 15, 2015

Chairman, Chicago Plan Commission Chairman, Conimittee on Zoning Room 1000 - City Hall Room 304 - City Hall Chicago, Illinois 60602 Chicago, Illinois 60602

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

The undersigned, Chris A. Leach, being first duly sworn, states as follows:

The undersigned certifies that he has complied with the requirements of § 17-13-0107 ofthe Chicago Zoning Ordinance and the requirements of § 16-4-100 of Chapter 194B-6.1 of the Lake Michigan and Chicago Lakefront Protection Ordinance, by sending the attached letter by USPS first class mail to property owners of the subject property and to property owners of all property within 250 feet of the property lines of the subject property, excluding public roads, streets, alleys, and other public ways, up to a maximum of 400 feet including public ways.

The undersigned certifies that the notice contained: the common street address and boundaries of the subject property; a description of the nature, scope and purpose of the application; the name and address of the applicant; the date that the applicant intends to file the application; and a source for additional information on the application and a statement that the applicant intends to file the application for a change in zoning on approximately September 15, 2015.

The undersigned certifies that he has made a bona fide effort to determine the names and last known addresses of the persons to be provided with notice by obtaining ownership information from the most recent authentic tax records of Cook County.

The undersigned certifies that the accompanying list is a complete list containing the names and last known addresses of the persons provided with notice.

The undersigned certifies compliance with all applicable written notice requirements.

Chris A. Leach

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

Notary Public

CONFIRMATION OF AUTHORITY

TO WHOM IT MAY CONCERN:

The undersigned, 33'" Street 1006 Michigan LLC, 131 West 33'''' 1006 Michigan

Avenue LLC, RK 2011 Trust 1006 Michigan Avenue LLC, and 1006 S Michigan LLC, as

Tenants in Common, are the owners of the property commonly known as 1006 S. Michigan

Avenue, Chicago, Illinois, hereby confirm that the Zoning Applicant, 1000 South Michigan

AvcnurLLC is authorized by the undersigned to file an Application for Amendment to the

Chicago Zoning Ordinance conceming the above-described property.

Dated this K|L day of August, 2015.

PROPERTY OWNERS:

33'" Street 1006 Michigan LLC

Robert Kantor, a Manager

RK 2011 T^st 1006 Michigan Avenue LLC

By:. Robert Kantor, a Manager

131 W9st 33'" 10Q6 Michigan Avenue LLC,

By:

lobert Kant(5'r,\i M^nager

1006 I^Michigan LLC

By:. iry Karl: p Manager



The undersigned, 33'" Street 1006 Michigan LLC, 131 West 33'" 1006 Michigan

Avenue LLC, RK 2011 Trust 1006 Michigan Avenue LLC, and 1006 S Michigan LLC, as

Tenants in Common, are the owners of the property commonly known as 1006 S. Michigan

Avenue, Chicago, Illinois, hereby confirm that the Zoning Applicant, 1000 South Michigan

Avcntte LLC is authorized by the undersigned to file an Application for Amendment to the

Chicago Zoning Ordinance conceming the above-described property.

Dated this Ji(_ day of August, 2015.

PROPERTY OWNERS:

33'" Street 1006 Michigan LLC 131 West 33'" 1006 Michigan Avenue LLC,



RK 2011 Trust 1006 Michigan Avenue LLC

By: Robert Kantor, a Manager

1006 SvMichigan LLC



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

April 6, 2009 and known as Trust number 1-09-111, the property owner ofthe property

commonly known as 920-1000 S. Michigan Avenue, Chicago, Illinois, hereby confirms that the

Zoning Applicant, 1000 South Michigan M'enuc LLC is authorized by the undersigned to file an

Application for Amendment to the Chicago Zoning Ordinance conceming the above-described

property. The zoning amendment to the Chicago Zoning Ordinance as authorized herein is

contingent upon the Zoning Applicant acquiring title to the subject property prior to the zoning

amendment ordinance being approved by the Chicago City Council.

lis Dated this i i L day of August, 2015.

PROPERTY OWNER:

First American Bank land Trust, 'Tmstee under U/T/A dated April 6, 2009 and known as Trust number 1 -09-111

By

Printed Name

Title

Exoneration provision restricting any liability of First American Bank attached hereto is expressly made a part hereof.

Exculpation of Trustee

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

NATIONAL SURVEY SERVICE, INC. ALTA/ACSM LAND TITLE SURVEY

]31nl of Suru f i j

y / i _ • ' y

I

9 '

©

1i li

S'ii

'/I I t

© ©

NOT WaUDED

! I

1-

© SOT ISCiVDED

© ©

• , f - ^

ifJQ

flei

1|-r - i j

"ri l!

. • • i - - T - l " - i ~ ' [ i K r ' - ' ' T • ' . - - • i " - ' [ " ' r - ' ' - : ' .^j.-TT--T--iTr->^

''1 ; 1 i i i i i i i i i i i i / f /

fl©:! 1

flei' I ' & — / \

1 BLOCK . 20 '

©.1 J I .

' © '

1© J

© / i ^" . : : -V7 <r i,^' . ' u ^ - ^ ' * iJ j / ; i _ y.'- -- - -,Tr P i r\ "

I •>'0 i

GRAPHIC SCALE

1 [ H O T nc M l 11

O O O TJ O TJ C* g. 3 o H 3 ="8

^ 9 5o3

CITY OF CHIGAGO

APPLICATION FOR AN AMENDMENT TO THE CHICAGO ZONING ORDINANCE

1. ADDRESS of the property Applicant is seeking to rezone;

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

2. Ward Niimber that property is located in: 4th Ward

3. APPLICANT 1000 South Michigan Equities LLC

ADDRESS 55 Fifth Avenue, 15th Floor CITY New York

STATE NY ZIP CODE 10003 PHONE 212-206-6097

EMAIL '•[email protected] CONTACT PERSON Robert Singer

4. Is the applicant the owner of the property? YES NO X If the applicant is not the owner of the property, please provide the following information regarding the owner and attach written authorization from the owner allowing the application to proceed.

OWNER Please see Exhibit A attached hereto.

ADDRESS CITY

STATE ZIP CODE PHONE.

EMAIL CONTACT PERSON

If the Applicant/Owner of the property has obtained a lawyer as their representative for the rezoriing, please provide the followirig information:

ATTORNEY 'Jobn J. George/Chris A. Leach, Schuyler, Roche & Crisham, P.C.

ADDRESS 180 N. Stetson Ave., Suite 3700

CITY Chicago STATE jL ZIP CODE 60601

PHONE (312) 565-8439 FAX (312)565-8300 EMAIL [email protected] [email protected]

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

1000 S Michigan JK Oak LLC

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

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

9. Present Zoning District DX-12 & DX-16 Proposed Zoning District DX-16 then to RBPD

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

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

12. Reason for rezoning the propertv T° redevelop the property with a new residential building while

retaining the existing ofl'ice building.

13. Describe the proposed use of the property after the rezoning. Indicate the number of dwelling units; number of parking spaces; approximate square footage of any commercial space; and height of the proposed building. (BE SPECIFIC)

To permit the construction of a 86 story residential tower building, with a height of 933' containing

506 dwelling units, ground floor retail space and 598 accessory parking spaces with the existing

office building to remain.

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

YESX NO

COUNTY OF COOK STATE OF EXINOIS

my nenjs i

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

South Michigan Equities LLC

Subsoibed and Sworn to before me this day of September . _ , 2015

Notary Public

Sis fpplicant

)uth Michigan Manager LLC

T L / m r f J j t . Manager

. KELLEY R. CHAFFEE Notafy Pubiic. Stats of New Yoifc

NO.01CH632802S OuaJffied In Nassau County

Commission Expires July 20,2019

For Office Use Only

Date of Introduction:

File Number:

Ward:

ZONING AMENDMENT APPLICATION

EXHBIT A

LIST OF ADDITIONAL PD PROPERTY OWNERS

APPLICANT:

ADDRESS:

1000 SOUTH MICHIGAN EQUITIES, LLC

920-1006 S. Michigan Ave., and 101 Wabash Ave., Chicago, Illinois

•1015 S.

SUB-AREA A:

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

SUB-AREA B TENANTS IN COMMON OWNERS:

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

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

RK 2011 Trust 1006 Michigan Avenue LLC 55 Fifth Avenue, 15"'Floor New York, New York, 10003 Contact: Robert Singer 212-206-6097 rsinger(^timeequities.com

1006 S Michigan LLC 2 Seaview Blvd. Port Washington, NY 11050 Contact: Jordan Karlik 516-622-7500 .Jordan(^jkequities.com

C I T Y O F C H I C A G O ECONO-fVlIC D I S C L O S U R E STATEMENT

AND A F F I D A V I T

SECTION 1 ~ G E N E R A L INFORMATION

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

1000 South Michigan Equities LLC '__

Check ONE of the fbllowing three boxes:

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

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

Applicant in which the Disclosing Party holds an interest: OR

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

B. Business address of the Disclosing Party; 55 Fifth Avenue, 15th Floor New York, New York, 10003

C. Telephone: (212)206-6097 Fa.x: Email: [email protected]

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

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

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

Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development

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

Specification # and Contract #

Vcr. 01-01-12 Page 1 of 13

SECTION II ~ D I S C L O S U R E OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

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

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

Illinois

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

[ ] Yes [ JNo M N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title 1000 South Michigan Manager LLC Manager 1000 South Michigan TEI Equities LLC Member

1000 S Michigan JK Oak, LLC Member

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

Pauc2of 13

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

Name Business Address Percentage Interest in the Disclosing Party

1000 South Michigan TEI Equities LLC 55 Fifth Avenue, 15th Floor _50% New York, New York, 10003

1000 S Michigan JK Oak LLC 55 Fifth Avenue, 15th Floor 50% New York, New York. 10003

SECTION 111 -- 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 M No

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

SECTION IV - D I S C L O S U R E OF SUBCONTRACTORS AND O T H E R RETAINED PARTIES

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

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

If the Disclosing Party is uncertain whether a disclosure is required under this Section, the Disclosing Party must cither 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. ôh^n J George Schuyler, Roche &_Crisham^PC _ Attorney _ $5,000 estimate

180 N Stetson Ave, Suite 3700 -Ghieage-ltiinois 6Q694

(Add sheets if necessary)

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

SECTION V - 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 [K] NO- [ ] No person directly or indirectly owns 10% or more ofthe Disclosing Party,

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

[ ] Y e s [ ] 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 1 is a continuing requirement for doing business with the City. .NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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

a. arc,not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;

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

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

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

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

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

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

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

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

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

Page 5 of 13

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

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

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

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

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

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

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

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

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

Patic6of 13

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

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

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

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[ ] is [K] is not

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

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

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

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13


D. CERTIFICATION REGARDING INTEREST IN CITY BUSINESS

Any words or terms that are defined in Chapter 2-156 ofthe Municipal Code have the same meanings when used in this Part D.

1. In accordance with Section 2-156-110 ofthe Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ]Yes IXiNo

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

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

Does the Matter involve a City Property Sale?

[ ]Yes [ ] N o

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

Name Business Address Nature of Interest

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

E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Page 8 of 13

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

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

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

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

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to infiuence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Paec9of 13

3. The Disclosing Party 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. 1. and A.2. above.

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

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[JYes [ ] N o

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 OlTice of Federal Contract Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ J N o

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

[JYes [ J N o

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

Page 10 of 13

SECTION V I I - - A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , DISCLOSURE

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and arc material inducements to the City's exccutioii of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicaKo.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

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

C. 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. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERM.^NENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.

The Disclosing Party represents and warrants that:

Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee. tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

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

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. i . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F. l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

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 furnished to the City.

1000 South Michigan Equiti

>ign here)

Robert Kantor

(Print or type name of person signing)

Manager of 1000 South Michigan, LLC, Manager of Disclosing Entity

(Pr int or type t i t le o f person s ign ing)

Signed and sworn to before me on (date) (jU>^.^Ûft^ o?b r ^ / S T

_ County , ( â te ) .

Commission expires: ~J_J^J_LfL.

Notary Public.

JOSEPHINE CINOUEMANl Page 12 of 13 Notary Public, State of New York

No. 4983831 Cii.Rlifiecl ill Bronx County ^

Commission Expires July 8, 2n / /

CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX A

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

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7,5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

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

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

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

[ J Yes [Xj No

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

Page 13 of 13


APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

[ JYes [XI No

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

[ JYes [ JNo [xJ Not Applicable

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

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

C I T Y OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I -- G E N E R A L INFORMATION

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

1000 S Michigan JK OAK, LLC

Check ONE of the following three boxes:

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

OR 2. [X] a legal entity holding a direct or indirect interest in the Property Owner. State the legal name

of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC OR

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

B. Business address of the Disclosing Party: ? SfiaviRw Rivd, in? Port Washington, NY 11050

C. Telephone: 516 622 7500 Fax: 516 224 7259 Email: [email protected]

D. Name of contact person: Jordan Karlik


F. Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to

which this EDS pertains. (Include project number and location of property, i f applicable):

Planned development application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this EDS?Department of Planning and Development

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


Ver. 01-01-12 Page 1 of 13

SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party:

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


Delaware


[ ] Yes [X] No [ ] N/A


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 ventiu-e, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title J K Equities L L C Manager

OAK Capitals L L C Manager

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

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. 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.


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

OAK Capitals L L C - 1250 S Michigan Ave, #1902, Chicago, I L 60605 50%

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


[ ] Yes [X] No

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



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 to Disclosing Party Address (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)

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

SECTION V - CERTIFICATIONS




[ J Yes [X] 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?

[ J Yes [ ] N o


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

Page 4 of 13

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

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

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




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



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

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

Page 5 of 13






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

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

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

7. 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 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"). N/A

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



[ ] is [X] is not



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

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

N/A

Page 7 of 13



Any words or terms that are defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D. '

1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes [X] No

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E.

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


[ ] 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:


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


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


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their tiBia\©3^pkiBdng Party has found no such records.

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

SECTION VI ~ 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 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.


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 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 niember of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreenient, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above. '

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

5. 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.




[ ] Yes [X] No



[ J Yes [ ] No

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

[ J Yes [ ] No


[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


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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


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.


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT 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 2-1 54-020 of the Municipal Code.


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.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such 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.


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

1000 S Michigan JK (Print drX ype name o

K, LLC sclosing Party)

J I L R R y K A R L I K (Ffrinôr type name of person signing)

MANAGER OF JK EQUITIES L L C , MANAGER OF DISCLOSING PARTY (Print or type title of person signing)

Signed and sworn to before me on (date) AU<!Û^f 2- , Z D ^ at )\(¥/7Si\\ County, îM Estate).

Commission expires

Notary Public.

Page 12 of 13

KaiEYHCHAFFBS MolBy PuMe, 8tBts or New Y M

^ i*x01CH6328026

tenmiMian Expires July 20,2O10


APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS AND DEPARTMENT HEADS

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

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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., 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 liniited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ J Yes [X] No


Page 13 of 13


APPENDIX B



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

[ JYes [XJNo

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

[ J Y e s [ ]No [XJ Not Applicable

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


C I T Y OF 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


S E C T I O N I " G E N E R A L INFORMATION


JK Equities, LLC


Indicate whether the Disclosing Party subniitting this EDS is:

1. [ J the Applicant OR

2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC

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

B. Business address of the Disclosing Party: ? SfiaviRw Blvd, lf)2 Port Washington, NY 11050





which this EDS pertains. (Include project number and location of prbperty, i f applicable):



D I f the Maftf^r is; a contract being handled by the City's Department of Procurement Services, please complete the following:


Vcr. 01-01-12 Page 1 of 13




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

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

Delaware


[ J Yes [XJ No [ J N/A


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

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

Name Title Jerry Karlik Manager/Member

Jordan Karlik Member

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

Page 2 of 13

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


Jerry Karlik - 2 SEAVIEW BLVD #102, PORT WASHINGTON, NY 11050 75%

Jordan Karlik - 2 Seaview Blvd #102, Port Washington, NY 11050 25%

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


[ J Yes [XJ No

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES


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

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

Page 3 of 13


N/A

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

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


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





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

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

[ J Yes [JNo


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

Page 4 of 13

2. The Disclosing Party and, 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:


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






connection with the Matter, including but not limited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties");

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

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

Page 5 of 13






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.


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

Page 6 of 13



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



[ J is [XJ is not



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

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

N/A

Page 7 of 13



Any words or terms that are defmed in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.


[ J Yes [XJ No

NOTE: If you checked "Yes" to Item D.l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.l . , proceed to Part E.



[ J Yes [J No

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





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor enthies regarding records of investnients or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their tlBls ©3 pkBsdng Party has found no such records.

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

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

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


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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.


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.




[JYes . [XJNo



[ J Yes [ J No


[ J Yes [ J No


[JYes [JNo


Page 10 of 13

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


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.


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


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.


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 wi 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. General 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 certifications.



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

J K Equities (Print lor type name /M)isclosing Party)

JiERRY K A R L I K


MANAGER (Print or type title of person signing)

Signed and sworn to before me pn (date)

at h i ( ' A ^ ^ . L \ County, / j / t ^ U s t state).

Notary Public. •..."iMT"'CHAFFEE

Na01O«32B028 Commission expires: Z f i T Q ( ^ . 0 « 2 ! f f i & J l t ^ ^ | g % , g

Page 12 of 13


APPENDIX A



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

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


[ J Yes [XJ No


Page 13 of 13


APPENDIX B




[ JYes [XJNo


[ JYes [ J N o [XJ Not Applicable





S E C T I O N 1 ~ G E N E R A L INFORMATION


OAK Capitals, LLC


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

OR


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

B. Business address of the Disclosing Party: i?.sn s Michigan AvpniiR - SiiitR ign? Chicago, IL 60605


D. Name of contact person: Ellas Abubeker






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


Ver. 01-01-12 Page 1 of 13

SECTION 11 ~ DISCLOSURE OF OWNERSHIP INTERESTS





Illinois


[ J Yes [J No . [XJ N/A


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

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

Name Title Elias Abubeker Managing Member

Min Ouyang Managing Member


Page 2 of 13



Elias Abubeker 1250 S Michigan Ave, #1902, Chicago, IL 60605 50%

Min Ouyang - 1250 S Michigan Ave, #1902, Chicago, I L 60605 50%

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


[ J Yes [XJ No



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.



Page 3 of 13


N/A










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 agreenient?

[ J Yes [JNo


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

Page 4 of 13












Page 5 of 13










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 ( i f none, indicate with "N/A" or "none"). N/A

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



[ J is [XJ is not



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

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

N/A

Page 7 of 13



Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.


[ J Yes [XJ No

NOTE: If you checked "Yes" to Item D.l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.

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


[ J Yes [J No






Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their 6Bl ^©a^pkIHing Party has found no such records.

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes 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 FOR F E D E R A L L Y FUNDED M A T T E R S

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



(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 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.)


Page 9 of 13







[ J Yes [XJ No



[JYes [JNo


[ J Yes [ J No


[ J Yes [ J No


Page 10 of 13

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


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.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .

Sedgwick St., Suite 500, Chicago, IL 60610, (3 12) 744-9660. The Disclosing Party must comply fully with 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 ( 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 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.


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the.City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. .NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1 -23 and Section 2-1 54-020 of the Municipal Code.


Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not Umited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.3 I f the Disclosing Party is the Applicant, the Disclosing Party wil 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 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.


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

s, L L C me of DiscflosSng Party)

(Sign here)

Elias Abubeker


MANAGER OF 1000 S Michigan J K OAK, L L C , MANAGING M E M B E R OF DISCLOSING PARTY

Signed and sworn to before mc on (date) A'-scs^ 9 7" ) o t ^ , County, 4 - ^ (state). at C <z}Cf>c<r

Notary Public.

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

Commission expires: O^/o^// ^_/,>/

Page 12 of 13


APPENDIX A




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


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo

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

[ J Y e s [ J N o [XJ Not Applicable


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

C I T Y OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I ~ G E N E R A L INFORMATION


1000 South Michigan TEI Equities LLC



OR 2. ^ a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the

Applicant in which the Disclosing Party holds an interest: 1000 South Michigan Equities LLC OR

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

B. Business address of the Disclosing Party: 55 Fifth Avenue, 15th Floor New York, New York, 10003

C. Telephone: (212) 206-6097 Fax: Email: [email protected]

D. Name of contact person: Robert Singer





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


Ver. 01-01-12 Page 1 of 13




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


Illinois


[ J Yes [JNo ^J N/A


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

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

Name Title Francis Greenburger ^^£!H9?I Robert Kantor Manager

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

Page 2 of 13



Francis Greenburger 55 Fifth Avenue, 15th Floor 19%

New York, New York, 10003

GT Holdings, LLC 55 Fifth Avenue, 15th Floor 76%

New YoTk, New 7or"R, T00D3 RK 2011 Trust 55 Fifth Avenue. 15th Floor 5%

New York, New York, 10003

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


[ J Yes M No



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

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


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.


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





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


[ J Yes [JNo


1. Pursuant to Municipal Code Chapter 1-23, Article 1 ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), 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: If Article 1 applies to the Applicant, the permanent compliance timeframe in Article 1 supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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


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



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




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

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

Page 5 of 13







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

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


Page 6 of 13


8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 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"). N/A

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



[ J is M is not



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

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13



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.


[ J Yes EK] 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.



[JYes [ JNo

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


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



Page 8 of 13


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



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



(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 ofthe Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to infiuence or attempt to infiuence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a niember of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreenient.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 50'1 (c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 5011(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".



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


[ J Yes [JNo


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

[JYes [JNo

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

[JYes [JNo


[JYes [JNo


Page 10 of 13







D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of infonnation contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

£. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT 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.


Page 11 of 13

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


F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F.l. , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

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

1000 South Michigan TEI Equities LLC

Disc/ôsing Party)

Robert Kantor


Manager

(Print or type title of person signing)

Signed and sworn to before me on (date) (JLLIÛM /Âs' at _ i s x ^ ^ j & & ^ _ _ _ County, / t ^ (Itate).

Notary Public.

Commission expires:

JOSEPHINE CINnUEMANl NetBry Public, State of New York

No. 4983831 Qualified in Bronx Co ui t

Page 12 of 13

g ijimission Expires July 8,


APPENDIX A



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

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

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

[ J Yes [Xj No


Page 13 of 13


APPENDIX B



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

[ JYes [XjNo

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

[ JYes [ JNo [xJ Not Applicable





SECTION I - G E N E R A L INFORMATION


GT Holdings, LLC



OR 2. a legal entity holding a direct or indirect interest in the Owner . State the legal name of the

Applicant in which the Disclosing Party holds an interest: 131 West 33rd Street 1006 Michigan Avenue, OR

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










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 I N T E R E S T S



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

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

Delaware


[ J Yes M No [ J N/A


1. List below the ful l names and titles of all executive officers and all directors ofthe 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).


Name Title Francis Greenburger Manager Robert Kantor Manager


Page 2 of 13

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


2003 Francis Greenburger Trust 55 Fifth Avenue, 15th Floor 75% New York, NY 10003

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


[ J Yes [Xj No


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 P A R T I E S


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


Page 3 of 13


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



[xJ Check 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



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

[ J Yes ^J No [ J No person directly or indirecfiy owns 10% or more of the Disclosing Party.


[JYes [ JNo


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

Page 4 of 13

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


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

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


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



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

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

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

Page 5 of 13





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

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

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



Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any fime during the 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"). N/A




[ J is ^J is not




I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13





[ J Yes [XJ No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ J Yes [ J No

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





Page 8 of 13





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




2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying acfivities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party 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 organizafion described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".



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.


[ J Yes [ J No

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


[ J Yes [ J No


[JYes [ JNo


[JYes [ JNo

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

Page 10 of 13

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


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 connecfion with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.



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 ( 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 Party to participate in other transacfions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the informafion provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


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.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 will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.



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

GT Holdings, LLC

(Print or tjme name of Disclos

(Sign here)



Signcyd aMswofn to before me onidate) fi'f^ ^

at JyC^lUlC Gounty, j n f ^ f j C \C _ (itate). ^

M f l l L M A V ^ Notary Pubiig'.ry FuWic, Stete of New Yc • u 4= - p - ^ . No.02V!6131(M0

Commission expires: | / . ' / J Qi'allt5sd in .iJew Yo.'fc Courrt' •

J

Page 12 of 13


APPENDIX A

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


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

"Applicable Party" means (1) all execufive officers of the Disclosing Party listed in Secfion H.B.l.a., i f the Disclosing Party is a corporafion; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, 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.


[JYes IxJNo


Page 13 of 13


APPENDIX B



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

[ JYes [XjNo

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

[ J Y e s [ J N o [xJ Not Applicable

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




S E C T I O N I ~ G E N E R A L INFORMATION

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

2003 Francis Greenburger Trust


Indicate whether the Disclosing Party submitfing this EDS is: 1. [ J the Applicant

OR 2. [x] a legal entity holding a direct or indirect interest in the Owner . State the legal name of the


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




E. Federal Employer Idenfificafion No. ( i f you have one):






Vcr. 01-01-12 Page 1 of 13




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


Delaware




I . 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, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar enfities, list below the legal titleholder(s).


Name Title Wilmington Trust Company Trustee

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

Page 2 of 13


Name

Isabelle Greenburger

Business Address Percentage Interest in the

Disclosing Party

55 Fifth Avenue, 15th Floor, New York. NY 10003 Beneficiary Noah Greenburger Claim Greenburger Julia Greenburger

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

Morgan Greenburger 55 Fifth Avenue, 15th Floor, New York, NY 10003 Beneficiary

S E C T I O N II I - BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ J Yes [XJNo


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


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


Page 3 of 13









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

[ J Yes ^J No [ J No person direcfiy or indirecfiy owns 10% or more of the Disclosing Party.


[ J Yes [ JNo


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

Page 4 of 13

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


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

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





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



Page 5 of 13




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


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

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



Page 6 of 13

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

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 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"). N/A

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



[ J is ^J is not



"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 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 ofthe privilege of doing business with the City."


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 statenients.




[ J Ycs [Xj No




[ J Yes [ J No

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




Please check cither 1. or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13




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




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

2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. I . above for his or her lobbying activifies or to pay any person or entity to influence or attempt to infiuence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organizafion described in secfion 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion 501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activifies".

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




[ J Yes [ J No



[ J Yes [ J No

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

[JYes [JNo


[JYes [JNo


Page 10 of 13

SECTION VII - A C K N O W L E D G M E N T S , C O N T R A C T INCORPORATION, C O M P L I A N C E , P E N A L T I E S , D I S C L O S U R E


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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The 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.


C. I f the City determines that any informafion provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( 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 Party to parficipate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By complefing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted in this EDS.

E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the informafion provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entifies delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking fickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Enfities wil 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. General Services Administration.





2003 Francis Greenburger Trust

(Print or tp pe name of

By:

(Sign here)



Signed and sworn to before mc pn (date) i ^ ^ K ) ^

at /l/fU Y^î^-j County, /^CWYOATC-(slate). ~^

l i I L i l . \ U f i K --jyrubli^SteteorNUvYc,; / / U X M - ^ ' NotaryPublic. No.02V!6131040 f j r Qi-'alrfjeti in New Yo* Count , -j

Commission expires: v W ' - ^ \ I . '

Page 12 of 13


APPENDIX A



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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Secfion n.B.i.a., 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 liniited partners of the Disclosing Party, i f 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 ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B




[ J Y e s [XJNo



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

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



S E C T I O N I - G E N E R A L INFORMATION


RK 2011 Trust


Indicate whether the Disclosing Party submitting this EDS is;


2. [x] a legal entity holding a direct or indirect interest in the Owner . State the legal name of the Applicant in which the Disclosing Party holds an interest: RK 2011 Trust 1006 Michigan Avenue LLC

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


C. Telephone: (212)206-6097 Fax: Email: [email protected]






I f the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following;

Specificafion # 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 I N T E R E S T S



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

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

New Jersey




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 fitleholder(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 enfity listed below must submit an EDS on its own behalf

Name Title Francis Greenburger Trustee [


Page 2 of 13 ^

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

Name

Jane Kantor


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

David Becker 55 Fifth Avenue, 15th Floor, New York, NY 10003 Beneficiary

Bryan Becker 55 Fifth Avenue, 15th Floor, New York, NY 10003 Beneficiary Elizabeth Katz 55 Fifth Avenue, 15th Floor, New York, NY 10003 Beneficiary

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


[ J Yes [Xj No

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

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



If the Disclosing Party is uncertain whether a disclosure is required under this Secfion, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13






SECTION V ~ C E R T I F I C A T I O N S



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



[ J Yes [ JNo


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

Page 4 of 13

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



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





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


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

Page 5 of 13

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


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




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.


7. I f the Disclosing Party is unable to cerfify to any of the above statements in this Part B (Further Cerfifications), the Disclosing Party must explain below; N/A

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wil l be conclusively presumed that the Disclosing Party cerfified to the above statements.


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



[ J is W is not




I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13

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 statenients.



1. In accordance with Section 2-156-110 of the Municipal Code: Docs any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [Xj No

NOTE: I f you checked "Yes" to Item D . I . , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[ J Yes [ J No

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




Please check cither 1. or 2. below. I f the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13




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

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



(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 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 ariy federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either; (i) it is not an organization described in secfion 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organizafion described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

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




[ J Yes [ J No



[JYes [ JNo

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

[JYes [ JNo


[ J Yes [ J No


Page 10 of 13







D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.

The Disclosing Party represents and warrants that;

Page 11 of 13

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.


F.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 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 cerfifications.

NOTE; I f the Disclosing Party cannot certify as to any of the items in F. l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.



RK 2011 Trust

(Sign here)



Signed and sworn to before me on (date) at IVrv/ / O Z - K Coupty, / I V W Y D V - ^

Commission expires;

'state).

-Gtary F ufjirc. State of New Yc NotaryPublic.^ No. 02VI6131040

QcaliffstJ in New Yorit Cbun^

Page 12 of 13


APPENDIX A



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

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

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

[ J Yes IxJ No

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

Page 13 of 13


APPENDIX B



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

[ JYes [XJNo

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


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


C I T Y O F C H I C A G O ECONO.MIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION 1 - G E N E R A L INFORMATION

A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:

1000 South Michigan Manager, LLC _


Indicate whether the Disclosing Party submitting this EDS is; 1. [ J the Applicant

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

Applicant in which the Disclosing Party holds an interest; OR

3. a legal entity with a right of control (see Section II .B. l . ) State the legal name ofthe entity in

which the Disclosing Party holds a right of control: J.009A9y*JlJ .i.?. J9^1^11' ^


C. Telephone: 12.12) 206-6097 Fax: Email: isin [email protected] ^


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

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



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

Specification # _ and Contract #

vor. 01-01-12 Page 1 of 13

SECTION II ~ D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


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

\)Q Limited liability company [ J Limited liability partnership [ J Joint venture [ J Not-for-profit corporation (Is the not-for-profit corporation also a 501(c)(3))?

[JYes [ JNo [ J Other (please specify)


Illinois

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

[ J Yes [ J N o [Xj N/A


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

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

Name Francis Greenburger Robert Kantor

Jerry Karlik '"EIias"A5'ube¥e7' "

Title Manager Manager

Manager Manager""

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

Page 2 of 13

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

Name

Francis Greenburger

Robert Kantor

Jerry Karlik

Elias Abubeker

Business Address

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

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

"T^FvTYorirWw'Y'orRTToB'OS"

8%

Percentage Interest in the Disclosing Party

4 1 %

25%

25%

S E C T I O N 111 - 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 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?

[ J Yes M No

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

SECTION IV - D I S C L O S U R E OF SUBCONTRACTORS AND 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 arc paid solely through the Disclosing Party's regular payroll.

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

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

Page 3 of 13






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




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

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

[JYes [ JNo


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

Pat;c4of 13

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

a. arc not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of government;


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

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




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

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

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

Page 5 of 13


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




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



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

Page 6 of 13

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

8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 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"). N/A

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



[ J is [KJ is not


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

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

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13




1. In accordance with Section 2-156-1 10 ofthe Municipal Code: Docs any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes M No

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



[JYes [ J N O

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


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



Page 8 of 13

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

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

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


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




2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to infiuence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperafive agreement.

Page 9 of 13


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

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




[JYes [ J N O


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

[ J Ycs [ J No

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

[JYes [ J N o


[ J Yes [ J NO

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

Page 10 of 13


The Disclosing Party understands and agrees that;

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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligafions on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.cityofchicago.ortj/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.



D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or othervv'ise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The infonnation provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party inust update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


Page 11 of 13

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

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

F.3 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 docs not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.

NOTE; If 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


1000 South Michigan Manager, LLC

(Print f r type nam^pTDidfclosing Party)

Robert Kantor


Manager of 1000 South Michigan, LLC, Manager of Disclosing Entity

(Pr int or type t i t le o f person s ign ing)

Signed and sworn to before mc on (date) J ^ A d sL pJ aoJL** , 1 at __L4<v: j!J5[_..__.._ County, A 4 ^ _ ' ^ 4 r - ^ ^ , (stato),^

_ Notary Public.

C{/Timission expires; 2v

JOSFPHIME CIMQUEMANI Page 12 of 13 Notary Public, Statf? ot New York

No, •iPfjasai Oi.'alififid in Bronx County ^

Commission Expires July 8, 20 / ' |


APPENDIXA



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

"Applicable Party" means (1) all executive officers of the Di.sclosing Party listed in Secfion II.B.l.a., if the Disclosing Party is a corporafion; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" moans the president, chief operafing ofticer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[JYes [XjNo

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

Page 13 of 13


APPENDIX B



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

I jYes |X |No

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

[ JYes [ JNo (xJ Not Applicable

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






1006 S Michigan, LLC


Indicate whether the Disclosing Party submitting this EDS is:

1. [XJ the Property Owner OR

2. [J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:

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

B. Business address of the Disclosing Party: 2 SRavlfiw Blvd. 102 Port Washington, NY 11050










Vcr. 01-01-12 Page 1 of 13




Person [XJ Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ ] Joint venture Sole proprietorship [ J 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)


Delaware


[X] Yes [J No [] N/A




Name Title Jerry Karlik Manager

Elias Abubeker Manager


Page 2 of 13



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

OAKS CAPITAL L L C - 1250 S MICHIGAN AVE #1902 CHICAGO, I L 60605 50%



[ J Yes [XJ No




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


Page 3 of 13








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



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

[ J Yes [JNo


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

Page 4 of 13

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


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




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



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

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

Page 5 of 13



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



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

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


7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13

I f the letters "NA," the word "None," or no response appears on the lines above, it wi l 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"). N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gif t" 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. N/A



[ J is [XJ is not

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


"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."

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

N/A

Page 7 of 13





[ J Yes [XJ No

NOTE; If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.l . , proceed to Part E.



[ J Yes [] No

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





Page 8 of 13


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

2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance policies. The Disclosing Party verifies that the following constitutes fu l 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



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); _


2. The Disclosing Party has not spent and wi l l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a meniber of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and inforrnation set forth in paragraphs A . l . and A.2. above.


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




[ J Yes [XJ No

If "Yes," answer the three questions below;


[ J Yes [ J No


[ J Yes [ J No


[JYes [JNo


Page 10 of 13



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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, inipose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


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


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13


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

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

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

CERTIFICATION


1006 S MICHIGAN L1.C (PripTor type name oCîsclosing Party)

ign h

JyERRY KARLIK int or type name of person signing)


Signed and sworn to before me on (date)Mj fLiji UTIOIS at N d ^ S ^ i U County, k J ^ (state).

Notary Public J l ^ . KElIEyR. CHAFFEE S-^. , - r , y / nf \ IPtSa i*i«"i»y PubHc, state of New Yak

Commission expires: ^ J l U i / / i J , U J r i Jto.01CH6328028 ^ / ^''^^ ' -QuaBfled In Nassau County

' «mfniasionE>ipiiTnJu|y2Q,ioi9 Page 12 of 13


APPENDIX A



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

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


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B


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

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

[ JYes [XJNo


[JYes [ J N o [XJ Not Applicable



CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT

SECTION I ~ GENERAL INFORMATION

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

JK 1006 S Michigan, LLC



OR 2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name

of the Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC OR

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

B. Business address of the Disclosing Party: 2 Reavlfiw Rlvrl, in? Port Washington, NY 11050





which this EDS pertains. (Include project number and location of property, if applicable):



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


Ver. 01-01-12 Page 1 of 13

S E C T I O N I I - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


1. Indicate the nature of the Disclosing Party;

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


Delaware

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

[JYes [XJNo [ J N / A


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

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

Name Title Jerry Karlik Manager

Michael Siemer Manager


Page 2 of 13



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

1006 Mich Office, L L C -111 E Wacker Drive, #900 Chicago, IL 60601 75%



[ J Yes [XJ No




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


Page 3 of 13


N/A

Business Relafionship to Disclosing Party Fees (indicate whether Address (subcontractor, attorney, paid or estimated.) N O T E :






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


[ J Yes ' [XJ No [ J No person direcfiy or indirecfiy owns 10% or more of the Disclosing Party.


[JYes [JNo


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

Page 4 of 13










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

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

Page 5 of 13










Page 6 of 13



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



[ J is [XJ is not



"We are not and wil l 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 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."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary); _

N/A

Page 7 of 13




1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee ofthe City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [XJ No

NOTE: If you checked "Yes" to Item D.l . , proceed to Items D.2. and D.3. I f you checked "No" to Itern D.l . , proceed to Part E.



[ J Yes [J No






Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their tiBis\©3 pkiKlng Party has found no such records.



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


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

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


Page 9 of 13







[JYes [XJNo



[ J Yes [ J No


[JYes [JNo


[JYes [JNo

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

Page 10 of 13

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






D. It is the City's policy to make this document available to the public on its Intemet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page I I of 13



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.


CERTIFICATION


JK 1006 S MICHIGAN L L C (Print or Jy e name of disclosing Party)

JERRY KARLIK (Priof or type name of person signing)


Signed and sworn to before me on (date) /I\A ^l/jJ"^ ^ ^ OltJ , N j y j /state).

signed and swori at County,

iissTon expires

Notary Public.

Commission expires

Page 12 of 13


APPENDIX A




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


[ J Yes [XJ No


Page 13 of 13


APPENDIX B



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

[ JYes [XJNo



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


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




JK Equities 1006, LLC



OR


OR 3. [J a legal entity with a right of control (see Section I I .B . l . ) State the legal name of the enfity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 2 Reaview Rlvd, 102 Port Washington, NY 11050

C. Telephone: 516 622 7500 • Fax: 516 224 7259 Email: [email protected]







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


Vcr. 01-01-12 Page 1 of 13




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


Delaware




I . List below the ful l nanies 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, liniited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title

J K Equities L L C Manager/Class B Member

Sikelele Investment Holdings L P Class A Member

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

Page 2 of 13

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


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

Sikelele Investment Holdings, LP, 6015 Yorkville Court, Dallas, TX 75248 10%



[ J Yes [XJ No






Page 3 of 13


N/A


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



SECTION V ~ CERTIFICATIONS



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


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

[JYes [JNo


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

Page 4 of 13










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


Page 5 of 13








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

7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below; N/A

Page 6 of 13



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 ( i f none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient. N/A



[ J is [XJ is not



"We are not and wi l l 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 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."

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

N/A

Page 7 of 13



Any words or terms that are defined in Chapter 2-1 56 of the Municipal Code have the same meanings when used in this Part D.


[JYes [XJNo

NOTE: If you checked "Yes" to Item D.l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D.l . , proceed to Part E.



[ J Yes [J No

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





Page 8 of 13


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


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



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 wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a meniber of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


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".



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


[ J Yes [XJ No



[ J Yes [ J No

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

[JYes [JNo


[ J Yes [ J No


Page 10 of 13

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


A. The certifications, disclosures, and acknowledgments contained in this EDS wi l 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.



C. I f the City determines that any informafion provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( 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 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.


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


Page 11 of 13

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


F.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.



J K Equities 1006 L L C (Print or type naine of Disclo;

By:

J E R R Y K A R I ^ K (Print or type name of person signing)

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

Signed and sworn to before me on (date) at AAh -S^V^ /7 / ^ n t v , / ^ ( ^ j o M ^ (state).

Notary Public.

.ommission expires

MICHAEL K BEETLE Notary PuUic - State of New York

NO. 01BE6097425 Qualified in Suffolk County

My Commlailon Eipirei Aup 18.2019

Page 12 of 13


APPENDIX A



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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operafing officer, executive director, chief financial officer, treasurer or secretary of a legal enfity or any person exercising similar authority.


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B


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


[ JYes [XJNo






AND AFFIDAVIT



Sikelele Investment Holdings, LP

Check ONE ofthe following three boxes:



ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC OR

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

B. Business address of the Disclosing Party: 6015 Ynrkville Court Dallas, TX 75248

C. Telephone: 972 248 8510 Fax: 972 248 7845 , Email: [email protected]

D. Name of contact person: Brian Rosenbloom



which this EDS pertains. (Include project number and location of property, if applicable):



E) If the Matter i«; a contract being handled by the City's Department of Procurement Services, please complete the following:


Ver. 01-01-12 Page 1 of 13

SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS


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

[J Limited liability company [ J Limited liability partnership [ J Joint venture [ J Not-for-profit corporation (Is the not-for-profit corporafion also a 501(c)(3))?

[ J Yes [ J No [ J Other (please specify)

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

Texas





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

Name

Brian Rosenbloom

Howard Kraines NKOSI Management Group L L C

Tifie

Manager/General Partner

Limited Partner

Manager


Page 2 of 13



Brian Rosenbloom 6015 Yorkville Court, Dallas, TX 75248 49.5%

_Howard Kraines 6018 Rose Grove Court, Dallas, TX 75248 49.5%

NKOSI Management Group LLC 6015 Yorkville Court, Dallas, TX 75248 1%



[ J Yes [XJ No




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


Page 3 of 13


N/A

Business Relationship to Disclosing Party Address (subcontractor, attorney,

lobbyist, etc.)







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



[ J Yes [JNo


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 confinuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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


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

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







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

Page 5 of 13

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









Page 6 of 13






[ J is [XJ is not



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

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

N/A •

Page 7 of 13





[ J Yes [XJ No

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to PartE.



[ J Yes [J No

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





Page 8 of 13


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



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


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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or enfity listed in Paragraph A . l . above for his or her lobbying acfivifies or to pay any person or enfity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperafive agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

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




[ J Yes [XJ No



[ J Yes [ J No


[ J Yes [ J No

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

[ J Yes [ J No


Page 10 of 13



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

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


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 parficipafion in the Matter and/or declining to allow the Disclosing Party to participate in other transacfions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connecfion with the public release of informafion contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted in this EDS.

E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the informafion provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13



F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.l. , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and^Q0mjjIeteas of the dalFfomisiied to the City.

Sikelele Investment Holdings LP (Print or type name of Disclosing Party)

By: (Sign here)

Brian Rosenbloom (Print or type name of person signing)

MEMBER OF JK EQUITIES 1006 L L C , MANAGER OF DISCLOSING PARTY (Print or type title of person signing)

Signed and sworn to before me on (date) at ( x ) X U y n ^ County, ^ J 2 ^ L £ \ S (state).

Notary Public.

Commission expires:

Page 12 of 13

LISA BEACH My Commission Expires

August 21, 2017


APPENDIX A



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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporafion; all partners of tiie Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers 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.


[ J Yes [X] No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo






AND AFFIDAVIT

SECTION I - GENERAL INFORMATION


Nkosi Management Group, LLC




ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S. Michigan, LLC OR

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

B. Business address of the Disclosing Party: 6015 Ynrkviiie Court Dallas, TX 75248

C. Telephone: 972 248 8510 Fax: 972 248 7845 Email: rosenbloom.brian@gmail com

D. Name of contact person: Brian Rosenbloom





G. Which City agency or department is requesting this EDS?Pepartment of Planning and Development

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


Ver. 01-01-12 Page 1 of 13



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


Texas




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

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

Name Tifie Brian Rosenbloom Sole Member


Page 2 of 13

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


Brian Rosenbloom 6015 Yorkville Court, Dallas, TX 75248 100%


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

[ ] Yes [XJ No






Page 3 of 13


N/A







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


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


[ J Yes [JNo


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

Page 4 of 13

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

. a. are not presenfiy debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transacfions by any federal, state or local unit of government;

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






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

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

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

Page 5 of 13

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






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


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

Page 6 of 13






[ J is [XJ is not



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

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

N/A

Page 7 of 13





[ J Yes [XJ No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.I . , proceed to Part E.



[ J Yes [J No

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





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their ttts\©3^pkiHing Party has found no such records.



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


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

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


Page 9 of 13

3. The Disclosing Party will submit an updated cerfification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and informafion set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party cerfifies that either: (i) it is not an organizafion described in secfion 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".





[JYes [XJNo



[ J Yes [ J No


[ J Yes [ J No

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

[ J Yes [ J No


Page 10 of 13



A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connecfion with the Matter, whether procurement, City assistance, or other City acfion, and are material inducements to the City's execution of any contract or taking other acfion with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.



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

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response tb a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connecfion with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. 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 of the Municipal Code.


Page 11 of 13



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 ofthe items in F.l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certificafierrs^d staterfferrts-CQntained in this EDS and Appendix A (if applicable) are true, accurate

complete as of the date fumisltbd^to the City.

Nkosi Management Group, L L C JPrint or type name of Disclosing Pa

By: (Sign here)

Brian Rosenbloom (Print or type name of person signing)

MANAGER OF S I K E L E L E INVESTMENT HOLDINGS LP , SOLE MEMBER OF DISCLOSING PARTY

Signed and ^worn to before me on (date) _ at County, (state).

Notary Public.

Commission expires: - A X V ^ ^ \ ^ T ^ H

o o A m m LISA BEACH

My Commission Expires August 21, 2017

^ w m

Page 12 of 13


APPENDIX A



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

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


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo









1006 Mich Office, LLC



1. [J the Property Owner OR

2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC

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

B. Business address of the Disclosing Party: 111 F Wanksr DrivR #gnn Chicago, IL 60601

C. Telephone: 312 819 4444 Fax; 312 819 5410 Email: [email protected]

D. Name of contact person: Mike Siemer




Planned development application for 920-1006 S Michigan Avenue and 1011-1015 South Wabash


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


Vcr. 01-01-12 Page 1 of 13



1. Indicate the nature ofthe Disclosing Party:

Person [XJ Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [JYes [ JNo Trust [ J Other (please specify)


Delaware


[XJ Yes [J No [J N/A




Name Title MHSR L L C C/O Michael Siemer Manager

SNJL L L C C/O Sherwin Jarol Manager

BMJ Investment Holdings L L C c/o Bradley Jarol Manager VJP Management L L C c/o Luke Jacob Pascale Manager


Page 2 of 13



MHSR L L C 111 E W A C K E R D R I V E #900 CHICAGO I L 60601 40%

SNJL L L C 111 E W A C K E R DRIVE #900 CHICAGO I L 60601 40%

BMJ Investment Holdings L L C 111 E Wacker Drive #900 Chicago I L 60601 15%

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


[ J Yes [XJ No


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 ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclpse employees who are paid solely through the Disclosing Party's regular payroll.

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


Page 3 of 13


N/A




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







[ J Yes [ JNo


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

Page 4 of 13











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









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


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 ( i f none, indicate with "N/A" or "none"). N/A




[ J is [XJ is not


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



N/A

Page 7 of 13





[ J Yes [XJ No




[JYes [JNo






Page 8 of 13


X I . The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their tfts\©3^pl»Klng Party has found no such records.





I . List below the names of all persons or enfities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter; (Add sheets i f necessary); _

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


Page 9 of 13







[ J Yes [XJ No



[JYes [ J N o


[JYes [ J N o

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

[JYes [ J N o


Page 10 of 13

S E C T I O N V I I ~ 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


A. The certificafions, 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 acfion, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.




D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-1 54-020 of the Municipal Code.


Page 11 of 13



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, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any of the items in F . l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

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

1006 Mich Office LLC (Print or type name of Disclosing Party)

By: (Sign here)

MICHAEL SIEMER (Print or type name of person signing)

MANAGER OF MHSR LLC, MANAGER OF DISCLOSING PARTY (Print or type title of person signing)

Signed and sworn to before me on (date) j-^ [J

at 0.60k. County, |||inT>I .S âte).

Commission expires:

Notary Public.

Page 12 of 13 AlliSONrMNO

NOTARY PUBUC - STATE OF ttXiNOIS mi


APPENDIX A




"Applicable Party" means (1) all executive officers ofthe Disclosing Party listed in Section II.B.l.a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f 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.


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B



1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ JYes [XJNo



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



AND AFFIDAVIT



MHSR, LLC


Indicate whether the Disclosing Party submitting this EDS is: 1. [J the Property Owner

OR

2. [XJ a legal entity holding a direct or indirect interest in the Property Owner. State the legal name ofthe Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC

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

B. Business address of the Disclosing Party; 111 F Wanker nrivR #flnn Chicago, IL 60601


D. Name of contact person: Mike Siemer








Ver. 01-01-12 Page 1 of 13






Delaware



B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY;



Name Tifie Michael Siemer Sole Member


Page 2 of 13



Michael Siemer U l E W A C K E R D R I V E #900 CHICAGO I L 60601 100%



[JYes [XJNo


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




Page 3 of 13


N/A











[ J Yes [ JNo


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

Page 4 of 13



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;







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

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

Page 5 of 13

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

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








Page 6 of 13






[ J is [XJ is not



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

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

N/A

Page 7 of 13




1. In accordance with Section 2-156-110 ofthe Municipal Code; Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [XJ No




[JYes [JNo






Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the-Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their ttts^©3^ptolI^ng Party has found no such records.


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



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 wil l be conclusively presumed that the Disclosing Party means that NO persons or enfities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an ofticer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy ofthe statements and information set forth in paragraphs A . l . and A.2. above.






[ J Yes [XJ No



[ J Yes [ J No


[ J Yes [ J No


[ J Yes [ J No

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

Page 10 of 13

S E C T I O N V I I ~ 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


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



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


E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. If the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13


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



CERTIFICATION


MHSR, LLC (Print or type name of Disclosing Party)

By: (Sign here)

MICHAEL SIEMER (Print or type name of person signing)

Sole Member (Print or type title of person signing)

Signed and sworn to before me on (date) at O o o f l - County, | ( l i n t l l ' ^ Jslate>.

M ( f m < \ . i < i U j h Notary Public.

Commission expires: 1 ^

p IO f iQ f AUJiSOWtKWG i-ageizOT l i I ( TARY PUBUC-STATE OF lUlNOiS

'*T1T'TTrsag«8Sflgfl3/i9


APPENDIX A


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

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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B. 1 .a., if the Disclosing Party is a corporation; all partners of the Disclosing Party, i f 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.


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo



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





A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;

SNJL, LLC



OR


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

B. Business address of the Disclosing Party: 111 F Wanker Drive #9nn Chicago, IL 60601


D. Name of contact person: Sherwin Jarol






— 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 I of 13



I . Indicate the nature of the Disclosing Party:

Person [XJ Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [JYes [ JNo Trust [ J Other (please specify)


Delaware

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




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

Name Title

Sherwin Jarol Sole Member

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

Page 2 of 13



Sherwin Jarol 111 E W A C K E R D R I V E #900 CHICAGO I L 60601 100%



[ J Yes [XJ No



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

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


Page 3 of 13


N/A











[ J Yes [ JNo


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

Page 4 of 13

2. The Disclosing Party and, i f the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B. 1. of this EDS;








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

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

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

Page 5 of 13










Page 6 of 13


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




[ J is [XJ is not

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


"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."

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

N/A

Page 7 of 13




1. In accordance with Section 2-156-1 10 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [XJ No

NOTE: I f you checked "Yes" to Item D . l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[JYes [JNo






Page 8 of 13


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

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





(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.)


Page 9 of 13


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' certificafions for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ J Yes [XJ No



[ J Yes [ J No


[ J Yes [ J No


[JYes [ J N o


Page 10 of 13



A. The certificafions, 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 2-1 56 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .


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


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.


Page 11 of 13






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 applicable) are true, accurate and complete as of the date furnished to the City.

SNJL L L C (Print or type na

By:

(Sign here)

Sherwin Jarol (Print or type name of person signing)


Signed and sworn to before me on (date) f V O l ) i ^ ' \ ^ | ^ ( ^ ' O l O t (Jate). -at County, l l l l lOI I g. i f c )

Commission expires:

Notary Public.

NOTARY PUBUC-I fOWBITIOtI

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all execufive 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 ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all pnncipal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ J Yes [XJ No

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

Page 13 of 13


APPENDIX B


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

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

[ JYes [XJNo



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


C I T Y OF C H I C A G O ECONOMIC D I S C L O S U R E S T A T E M E N T

AND AFFIDAVIT



BMJ Investment Holdings, LLC




of the Property Owner in which the Disclosing Party holds an interest: 1006 S Michigan, LLC OR

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

B. Business address of the Disclosing Party: 111 F War.ker nrivp #Qnn ; Chicago, IL 60601


D. Name of contact person: Sherwin Jarol








Ver. 01-01-12 Page 1 of 13




Person [XJ Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [JYes [ J N o Trust [ J Other (please specify)


Delavyare




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


Name Title

Bradley Jarol Sole Member


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.


Bradley Jarol 111 E W A C K E R DRIVE #900 CHICAGO I L 60601 100%

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


[ J Yes [XJ No






Page 3 of 13


N/A











[ J Yes [ JNo


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

Page 4 of 13












Page 5 of 13



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







Page 6 of 13






[ J is [XJ is not



"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 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."


N/A

Page 7 of 13





[JYes [XJNo

NOTE: I f you checked "Yes" to Item D. l . , proceed to Items D.2. and D.3. I f you checked "No" to Item D. I . , proceed to Part E.



[JYes [JNo

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





Page 8 of 13


X 1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their tlliB\©3^pk»Klng Party has found no such records.



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



(If no explanation appears or begins on the lines above, or i f the letters "NA" or if 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 ofthe Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a meniber of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


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".





[ J Yes [XJ No



[JYes [ J N o


[ J Yes [ J No


[JYes [ J N o

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

Page 10 of 13








E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


Page 11 of 13

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

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


NOTE: I f the Disclosing Party cannot certify as to any of the items in F. I . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.



BMJ Investment Holdings L L C (Print or type name of Displesing Rarfy)

(Sign here)

Bradley Jarol



Signed and sworn to before me on (date) at County, l i l l i n n i S ^(stale).

Commission expires:

Notary Public.

Page 12 of 13


APPENDIX A



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

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


[ J Yes [XJ No

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

Page 13 ot 13


APPENDIX B



1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ JYes [XJNo



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





A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable:

VJP Management, LLC


Indicate whether the Disclosing Party submitting this EDS is; 1. [J the Property Owner

OR


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

B. Business address of the Disclosing Party: 111 F Wanker Drive #Qnn Chicago, IL 60601


D. Name of contact person: Luke Jacob Pascale






I f the Matter is a contract being handled by the City's Department of Procurement Services, please

complete the following;


Vcr. 01-01-12 Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S


1. Indicate the nature ofthe Disclosing Party:


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

Delaware


[XJ Yes [J No [] N/A




Name Tifie

Luke Jacob Pascale Sole Member


Page 2 of 13

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


Luke Jacob Pascale 111 E W A C K E R DRIVE #900 CHICAGO I L 60601 100%



[ J Yes [XJ No


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


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


Page 3 of 13


not an acceptable response. N/A







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


[ J Yes [ J No


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

Page 4 of 13




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








Page 5 of 13










Page 6 of 13



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



[ J is [XJ is not



"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 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 theMoss of the privilege of doing business with the City."

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

N/A

Page 7 of 13

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




[JYes [XJNo


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


[JYes [JNo

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




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


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

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







Page 9 of 13


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".





[ J Yes [XJ No



[JYes [ J N o

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

[JYes [ J N o


[JYes [ J N o


Page 10 of 13



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





E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13

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



NOTE: I f the Disclosing Party cannot cerfify as to any of the items in F. l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.


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

VJP Managment L L C (Print or type name of Disotasing Party)

By:

Luke Jacob Pascale (Print or type name of person signing)


Signed and sworn to before me on (date) /j|/fl|/<.{"f" / ^ ^ / ^ Q at P. 00 l l ^ County, [ [ l i n p i S> ^(state).

Commission expires; ^ j ^ ^

Notary Public.

Page 12 of 13


APPENDIX A




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


[ J Yes [XJ No

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

• •'••'A.. ;

Page 13 of 13 ' *-''^-v'»-^«.*. vv:..< .,-*, ...>


APPENDIX B




[ JYes [XJNo

2. I f the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scoffiaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?


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


C I T Y OF C H I C A G O ECONOMIC DISCLOSURE S T A T E M E N T



A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;




1 • EK] the Owner of property located at 1006 South Michigan Avenue OR


OR 3. [ J a legal entity with a right of control (see Secfion II .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control;


C. Telephone; (212) 206-6097 Fax: Email: [email protected]


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






Ver. 01-01-12 Page 1 of 13






Illinois


[ J Ycs [ J No [xJ N/A


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




Page 2 of 13

interest of a niember or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 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.


RK2011 Trust 55 Fifth Avenue, 15th Floor 100% New York, NY 10003

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


[ J Yes [xJ No


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




Page 3 of 13



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


[Xj 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



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

[ J Yes [ J No ^J No person directly or indirecfiy owns 10% or more of the Disclosing Party.


[ J Yes [ JNo


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

Page 4 of 13









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

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

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

Page 5 of 13


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

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






7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certificafions), the Disclosing Party must explain below: N/A

Page 6 of 13


8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 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"). N/A

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


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

[ J is ^J is not



"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 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."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13





[ J Yes [Xj No


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


[ J Yes [ J No

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





Page 8 of 13


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


SECTION 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



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

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

2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A. 1. above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreenient.

Page 9 of 13


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 wil l not engage in "Lobbying Activifies".

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




[ J Yes [ J No

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

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

[ J Yes [ J No


[JYes [ J N o


[ J Yes [ J No

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

Page 10 of 13



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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .




E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 of the Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page I I of 13


F.2 I f the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities wil 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. General Services Administration.


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



(Print orftype narne of Disclosing Party)

(Sign here)


(Print or type fitle of person signing)

Signed and sworn to before me-pn (date) / / l ^ t S at M v IJ/^ i ^ County, m ^ J W ^ j C (state).

iiiCHAfvU'VlEiiji f i T • •'Clary Fublic, Stale of New Yo ^ NotaryPublic^ No. 02VI6131C40

Qualifisd in New Yo* County

Commission expires; v J ^ ' ^ " ' ^1 . ~^ .

Page 12 of 13


APPENDIX A



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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l .a., i f the Disclosing Party is a corporation; all partners ofthe Disclosing Party, i f 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.


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B



1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Secfion 2-92-416 of the Municipal Code?

[ JYes [XJNo



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






131 West 33rd 1006 Michigan Avenue, LLC



1. ^ the Owner of property located at 1006 South Michigan Avenue OR


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


C. Telephone; (212) 206-6097 Fax: Email; [email protected]



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);





Vcr. 01-01-12 Page 1 of 13




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

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

Illinois


[ J Yes [ J No [xJ N/A


1. List below the ful l names and titles of all executive officers and all directors ofthe 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 meniber, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.



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.


131 West 33rd Street Holdings, LLC 55 Fifth Avenue, 15th Floor 100% New York, NY 10003

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


[ J Yes [xJ No




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

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

Page 3 of 13








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


[ J Yes [ J No ^J No person directly or indirecfiy owns 10% or more of the Disclosing Party.


[ J Yes [ J N o


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

Page 4 of 13







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




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

Page 5 of 13

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






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


7. I f the Disclosing Party is unable to cerfify to any of the above statements in this Part B (Further Certifications), the Disclosing Party must explain below: N/A

Page 6 of 13


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"). N/A

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



[ J is ^J is not

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


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

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Secfion 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13





[ J Yes [Xj No

NOTE: I f you checked "Yes" to Item D.L , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.

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


[ J Yes [ J No

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





Page 8 of 13

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



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



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):


2. The Disclosing Party has not spent and wil l not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A. 1. and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and 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' cerfifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[JYes [ J N o


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

[ J Yes [ J No


[JYes [ J N o


[ J Yes [ J No


Page 10 of 13

S E C T I O N V I I - 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


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

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transacfions. The ful l 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.


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


E. The informafion provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-1 54-020 ofthe Municipal Code.


Page 11 of 13

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




CERTIFICATION

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

131 West 33rd Street 1006 Michigan Avenue, LLC

(Print or type name of Diisclosing Party)

By: (Sign here)

g e g g ^ y:4^>^(^ (Print or type name of person signing)


Signed and sworn to before me an (date) j N h P j ^ \

at / V f V f ^ A t l Ceunty, JyJU h rX-(state) .

XI t D , , . --i20fFu!jlic State Of New Yo;.' NotaryPublic. No. 02VI6131040

/ A /) . Qi "aliiied in New York County/—^

Commission expires;

Page 12 of 13


APPENDIX A



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

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

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

[ J Yes [xJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo



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






131 West 33rd Street Holdings, LLC

Check ONE of the following three boxes;

Indicate whether the Disclosing Party submitting this EDS is; 1. [ J the Applicant

OR 2. ^ a legal entity holding a direct or indirect interest in the Owner . State the legal name of the


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


C. Telephone; (212)206-6097 Fax; Email: [email protected]

D. Name of contact person; Robert Singer


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);





Vcr. 01-01-12 Page 1 of 13




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


Delaware




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




Page 2 of 13



Francis Greenburger 55 Fifth Avenue, 15th Floor 25% New York, NY 10003

GT Holdings, LLC 55 Fifth Avenue, 15th Floor 75% New York, NY 10003

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


[ J Yes [Xj No

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



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


Page 3 of 13












[ J Yes [ JNo


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

Page 4 of 13

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


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




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




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

Page 5 of 13



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




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


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

Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any fime during the 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"). N/A

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



[ J is ^J is not


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


I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13




1. In accordance with Section 2-156-110 of the Municipal Code; Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [XJ No

NOTE; I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.

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


[ J Yes [ J No






Page 8 of 13



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


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.


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);



Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in secfion 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[ J Yes [ J No



[ J Yes [ J No

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

[ J Yes [ J No


[ J Yes [ J No


Page 10 of 13



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 execufion of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.





E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 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.


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.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION

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

131 West 33rd Street Holdings, LLC

(Sign here)



Signed and swor led and sworn to before me Qnj-(da-te) m M j I i r l C f o u m - , . W W Yu/iClfslate). ^

N otary Publ,lfc{ary Fufjiic. State of New Yo No.02V!6131040

'2^0 I I QL;aHfisd in New York County Commission expires; U lM^ J ' " IT

Page 12 of 13


APPENDIX A



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

"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Section II.B.l.a., 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, 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.


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B




[ J Y e s [XJNo







S E C T I O N 1 ~ G E N E R A L INFORMATION

A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ i f applicable;

33rd Street 1006 Michigan Avenue, LLC


Indicate whether the Disclosing Party submitfing this EDS is:

1. ^ the Owner of property located at 1006 South Michigan Avenue OR

2. [J a legal enfity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:

OR 3. [J a legal entity with a right of control (see Section I I .B. l . ) State the legal name of the entity in which the Disclosing Party holds a right of control; •










Ver. 01-01-12 Page 1 of 13




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


Illinois


[ J Yes [ J No [xJ N/A


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 enfities, list below the legal titleholder(s).

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



Page 2 of 13

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

Name Business Address

33rd Street Holdings, LLC 55 Fifth Avenue, 15th Floor

Percentage Interest in the Disclosing Party 100%

New York, NY 10003



[JYes [xJNo


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 P A R T I E S

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

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

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

Page 3 of 13





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





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


[ J Yes [ JNo


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

Page 4 of 13

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


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

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


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




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

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

Page 5 of 13






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

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


7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certificafions), the Disclosing Party must explain below: N/A

Page 6 of 13



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



[ J is ^J is not


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

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

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13





[ J Yes [Xj No




[JYes' [ JNo

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


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



Page 8 of 13


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


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





2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying acfivifies or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party will submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statenients and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organizafion described in secfion 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".





[ J Yes [ J No



[JYes [ J N o


[ J Yes [ J No


[ J Yes [ J No

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

Page 10 of 13

S E C T I O N V I I - A C K N O W L E D G M E N T S , CONTRACT 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


A. The certifications, disclosures, and acknowledgments contained in this EDS wil l become part of any contract or other agreenient between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N .




E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article 1 of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


Page 11 of 13

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





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

33rd Street 1006 Michigan Avenue, LLC

(Print or type name pf Disclosing Party)

(Sign here)


(Print or type fitle of person signing)

Signed and sworn to before me pn (dale) ^ I M I A ^ V

at \ J i \ J ^ ^ f \ L County, | v f V j 7 6 r ^ " (state).

i' iCHAROViEST Notary Public. f-ictary Public, State of New Yorr

N0.02VI6131C40 / I 7 (— ^ , —7 Qualified in New York County ; -j

Commission expires; L/ V S ^ ^ I / . Ccnvv.ission Expires Juiy ?.5,20 f_ /

Page 12 of 13


APPENDIX A



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

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


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B



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

[ JYes [XJNo



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






33rd Street Holdings, LLC

Check ONE ofthe following three boxes;


OR 2. a legal entity holding a direct or indirect interest in the Owner . State the legal name of the

Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC

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


C. Telephone: (212) 206-6097 Fax; Email: [email protected]

D. Name of contact person; Robert Singer

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



G. Which City agency or department is requesfing this EDS? Department of Planning and Development



Vcr. 01-01-12 Page 1 of 13




Person [xJ Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ J Yes [ JNo Trust [ J Other (please specify)


Delaware




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


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

Page 2 of 13

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

Name Business Address

West Willows Equities, LLC 55 Fifth Avenue, 15th Floor

Percentage Interest in the Disclosing Party

100% New York, NY 10003

SECTION 111 ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ J Yes [XJNo


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


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


Page 3 of 13





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





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


[ J Yes [ J N o


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 cerfifies as follows; (i) neither the Applicant nor any controlling person is currenfiy indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or con.spiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee ofthe City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

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


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







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

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

Page 5 of 13



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




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



Page 6 of 13






[ J is ^J is not



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

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Secfion 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13




1. In accordance with Section 2-156-110 of the Municipal Code; Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [Xj No




[ J Yes [ J No

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




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

Page 8 of 13







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



Page 9 of 13


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

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




[ J Yes [ J No



[ J Yes [ J No

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

[ J Yes [ J No


[JYes [JNo


Page 10 of 13



A. The cerfifications, 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.citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.




E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page I I of 13

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


F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F . l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.



33rd Street Holdings, LLC

(Sign here)


AAP^f><3^-^ (Print or type tifie of person signing)

Signed ^rid swprn to before me on (d-ate) at f^f U Ar 1^ County, fJfU /O rV_((tate). '

Notary Publiectafy Public, State of New Yor:-

Commission expires._» » < ^

Y ' l . ^ N0.02VI6131C40

Page 12 of 13


APPENDIX A



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

"Applicable Party" means (1) all execufive officers ofthe Disclosing Party listed in Section II.B.l.a., i f the Disclosing Party is a corporafion; all partners of the Disclosing Party, i f the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, i f 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.


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo



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






West Willow Equities, LLC



OR 2. \x\ a legal entity holding a direct or indirect interest in the Owner . State the legal name of the

Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC OR

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










Ver. 01-0M2 Page 1 of 13

SECTION II - D I S C L O S U R E OF OWNERSHIP I N T E R E S T S




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

New York




1. List below the full names and titles of all executive officers and all directors of the enfity. NOTE: For not-for-profit corporations, also list below all members, 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).




Page 2 of 13

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


Park Place Equities, LLC 55 Fifth Avenue, 15th Floor 100% New York, NY 10003



[ J Yes [Xj No


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 P A R T I E S


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


Page 3 of 13










[ J Yes M No [ J No person directly or indirecfiy owns 10% or more ofthe Disclosing Party.


[ J Yes [ JNo


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 idenfified in Section I I . B . l . of this EDS;


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



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





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

Page 5 of 13



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







Page 6 of 13


8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 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"). N/A




[ J is ^J is not

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



I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13





[ J Yes [Xj No

NOTE; If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.



[ J Yes [ J No

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





Page 8 of 13


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





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

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it 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 meniber of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in secfion 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organizafion described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activifies".





[ J Yes [ J No


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

[ J Yes [ J No


[JYes [JNo


[JYes [JNo

If you checked "No" to question I . or 2. above, please provide an explanafion;

Page 10 of 13



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 arc material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.



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 ( i f not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or decHning to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the informafion provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of informafion contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Departnient of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13



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, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.

NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.



West Willow Equities, LLC (Print or^ype name of E\isclos|pg Parlj

B y : _ _ (Sign here)



Signed arrd/sworn to before rnaon^date), at ( \ f ( U / ^ H ^ C o u i v t v , f 7 / K j D r / t - (slate).

NotaryPublic. ' ,

Commission expires: U ( ^ ^ 1 J ^ T - ^ 1 ^ • - ^

Page 12 of 13 ^


APPENDIX A



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

"Applicable Party" means (I) all executive officers ofthe Disclosing Party listed in Section II.B.l .a., 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 ofthe Disclosing Party, i f the Disclosing Party is a limited parmership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal enfity or any person exercising similar authority.

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

[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B




[ JYes [XJNo









Park Place Equities, LLC


Indicate whether the Disclosing Party submitting this EDS is;


2. Dd a legal entity holding a direct or indirect interest in the Owner . State the legal name of the Applicant in which the Disclosing Party holds an interest: 33rd Street 1006 Michigan Avenue, LLC

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


C. Telephone: (212)206-6097 Fax: Email: [email protected]








Ver. 01-01-12 Page 1 of 13




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


New York


[JYes M N o [ J N / A


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

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



Page 2 of 13

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

Name

Rupertsland Holdings, lnc


Disclosing Party 55 Fifth Avenue, 15th Floor, New York, NY 10003 14.89%

New Regime Co, LP 55 Fifth Avenue, 15th Floor, New York, NY 10003 16.11%

Robert Kantor 55 Fifth Avenue, 15th Floor, New York, NY 10003 10.55% Francis Greenburger 55 Fifth Avenue, 15th Floor, New York, NY 10003 29.53%

S E C T I O N II I ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ J Yes [Xj No


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 RETAINED PARTIES


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


Page 3 of 13



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







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


[ J Yes [JNo


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

Page 4 of 13

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



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







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

Page 5 of 13

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






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



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 cerfified to the above statenients.

8, To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 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"). N/A

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



[ J is ^J is not

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



I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary); N/A

Page 7 of 13




1. In accordance with Section 2-156-110 ofthe Municipal Code; Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ J Yes [Xj No

NOTE: I f you checked "Yes" to Item D.L , proceed to Items D.2. and D.3. I f you checked "No" to Item D . l . , proceed to Part E.



[JYes [ J N o

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:





Page 8 of 13



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


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


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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a meinber of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party 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 statenients and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that cither; (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[JYes [ J ' N O



[ J Yes [ J No


[ J Yes [ J No


[JYes [ JNo

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

Page 10 of 13



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 acfion with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.



C. I f the City determines that any informafion provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement ( 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 Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any informafion submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the fime the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT I N E L I G I B I L I T Y for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 of the Municipal Code.


Page 11 of 13


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

F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certificafions equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.

NOTE: I f the Disclosing Party cannot certify as to any ofthe items in F. l . , F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

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

Park Place Equities, LLQ

(Print or tvpo\nam

By:

(Sign here)



Signed and sworn to before me on (date) fi^Ml- ItZ^f^ at /i/iJjOjrJL_ Qounty, /lAwViy^fC (Jtate).

Notary Publj9.p,;S|£stet8 0fNewY^ ' I I ^ , ^ ' N0.02VI6131C40

^ / , / -7 7 0 / / \;:=aIif>s<JlnN6vvYorkCoim'-Commission expires; */ C,/^ / ^--^ / /. | ^

Page 12 of 13


APPENDIX A


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

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

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

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

[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B



1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner idenfified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ JYes [XJNo












OR 2. ^ a legal entity holding a direct or indirect interest in the Owner . State the legal name of the


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


C. Telephone: (212) 206-6097 Fax: ; Email; [email protected]








Vcr. 01-01-12 Page 1 of 13



1. Indicate the nature ofthe Disclosing Party;

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

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

New York




1. List below the ful l names and fifies of all execufive officers and all directors of the enfity. 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 fifieholder(s).




Page 2 of 13

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


Francis Greenburger 55 Fifth Avenue, 15th Floor 14.89% ,_ New York, NY 10003

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


[ J Yes [Xj No

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



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


Page 3 of 13





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





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


[ J Yes [ JNo


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

Page 4 of 13

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


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







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

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

Page 5 of 13






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

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


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

Page 6 of 13

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

8. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 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"). N/A

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



[ J is ^J is not

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


"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 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."


Page 7 of 13





[ J Yes [Xj No




[ J Yes [ J No






Page 8 of 13


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







2. The Disclosing Party has not spent and wil l 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


4. The Disclosing Party certifies that either: (i) it is not an organizafion described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organizafion described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

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




[JYes [JNo



[ J Yes [ J No


[JYes [ J N o


[JYes [ J N o


Page 10 of 13










Page 11 of 13



F.3 I f the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F . l . and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.



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 t^pe name off Disclosing Party)

(Sign here)



Signe(L^nd>^wornj tp before ma on (âtc) , at ounty, (state).

M M ^ I y } ^ Nou,ry Public, • , . ^ & S T ^ ^ o . ^ , ^

Commission expires; " (

Page 12 of 13


APPENDIX A



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

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


[ J Yes IXJ No

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

Page 13 of 13


APPENDIX B



1. Pursuantto Municipal Code Section 2-154-010, is the Applicant or any Owner identified asa building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ JYes [XJNo



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





A. Legal name ofthe Disclosing Party submitting this EDS. Include d/b/a/ if applicable;

New Regime Co. LP



OR 2. M a legal entity holding a direct or indirect interest in the Owner . State the legal name of the


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




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






Vcr. 01-01-12 Page I of 13




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


New York

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



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 fitleholder(s).


Name Tifie Francis Greenburger Manager Robert Kantor Manager

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

Page 2 of 13

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

Name

Lillian Jaffe Trust

Business Address Percentage Interest in the Disclosing Party

55 Fifth Avenue, 15th Floor, New York, NY 10003 3.54% RKP Revocable Declaration of Trust Eil^pn Westbaum

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

1.77% 2 65%

Patricia and Thomas Carren 55 Fifth Avenue, 15th Floor, New York, NY 10003 2.65%

Uebra Chwast Kevocable 1 rust Jeffrey Newmark

bb Fifth Avenue, Ibth Floor, New York, NY 1U003 55 Fifth Avenue, 15th Floor, New York, NY 10003

2.6b% 1.33%

Johnathan Newmark Living Trust 55 Fifth Avenue, 15th Floor, New York, NY 10003 1.33%

S E C T I O N II I ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D O F F I C I A L S


[ J Yes [XJNo


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 P A R T I E S


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


Page 3 of 13










[JYes ^J No [ J No person directly or indirecfiy owns 10% or more ofthe Disclosing Party.


[ J Yes [ JNo


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

Page 4 of 13

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


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







Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation; interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management,,ownership7or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity;

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

Page 5 of 13







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.


7. I f the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Cerfifications), the Disclosing Party must explain below: N/A

Page 6 of 13






[ J is J is not



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

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

Page 7 of 13





[ J Yes [Xj No

NOTE: I f you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to Part E.

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


[ J Yes [ J No

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





Page 8 of 13




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

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


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

(If no explanafion appears or begins on the lines above, or i f the letters "NA" or i f the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or enfity listed in Paragraph A . l . above for his or her lobbying acfivifies or to pay any person or enfity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party 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 secfion 501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and wil l not engage in "Lobbying Activities".





[ J Yes [ J No



[ J Yes . [ J No


[JYes [ J N o


[ J Yes [ J No

I f you checked "No" to quesfion I . or 2. above, please provide an explanation;

Page 10 of 13



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 execufion of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.




D. It is the City's policy to make this document avafiable to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By complefing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.



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.3 If the Disclosing Party is the Applicant, the Disclosing Party wifi obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.


CERTIFICATION


New Regime Co. LP

(Print or type name of Disclosing Party)

(Sign here)



ckte) J^jîiWrrôif UA\L(date). ^

Notary Public, 'c^sty Fublic, State of NsvvYo N0.02VI6131C40 J l N0.02V!6131M0

/ 7 >7 1 o •'?;>aIirradinNewYo.'kC0or»t' , Commission expires

Page 12 of 13


APPENDIX A




"Applicable Party" means (1) all executive officers of the Disclosing Party listed in Secfion 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 partaership; 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 Domesfic Partner thereof currenfiy have a "familial relationship" with an elected city official or department head?

[ J Yes IXJ No

If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to which such person is connected; (3) the name and tifie of the elected city official or department head to whom such person has a familial relafionship, and (4) the precise nature of such familial relafionship.

Page 13 of 13


APPENDIXB




[ JYes [XJNo



If yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scoffiaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.



AND AFFIDAVIT



First American Bank, not personally, but as Trustee U/T/A dated April 6, 2009 ahd known as Trust numbfer 1-09-111.



1. M the Property Owner OR

2. [ J a legal entity holding a direct or indirect interest in the Applicant. State the legal name of the Applicant in which the Disclosing Party holds an interest:

OR 3. [ J a legal entity with a right of control (see Section ILB.l.) State the legal name ofthe entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: ?IR wp t Main strpst. Wpst niinrifip>. liiinnis Rniia

C. Telephone: (847)403-8109 Fax: (847)403-8109 Email: [email protected]

D. Name of contact person: Dawn Griffin

E. Federal Employer Identification No. (if you have one):, _ ^

F, Brief descripfion of contract, transaction oi sither undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if applicable):

Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabasli.




Ver. 01-01-12 Page 1 of 13 DM2\605629S,I


A. NATURE OFTHE DISCLOSING PARTY

I . Indicalc llie nature of tlic Di,sclosing i'lirty: I I'crson [ ] Limited liability company ] Publicly registered business corporation [ ] Limited liability partnership ] Privately held business corporation [ ] Joint venture 1 Sole proprietorship f ] Not-for-profit corporation I General partnership (Is the not-for-profit corporation also a 501(c)(3))? ] Limited partnership [ ] Yes [ ] No

[x] Trust [ J Other (please specify)


Illinois


[ ] Ycs [ 1 No [X] N/A


I . List below the full names and titles of all executive officers and all directors of the entity. NOTE: For not-for-profit corporations, also list below all members, if any, which are legal entities. If there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal litleholder(s). First American Bank is the Tmstee of Trust # 1-09-111.

If the entity is a general partnership, limited partnership, limited liability company, limited liabiUty partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE; Each legal entity listed below must submit an EDS on its own behalf.

Name Title •lana Naqpil Fypir.utlva Vine Prfislrient Dawn Griffin Senior Vice President

Beverly C. Hayes Vice President

Rosanne M, DuPass Vice President

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7,5% of the Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture,

Page 2 of 13

interest of a member or manager in a hmited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None;" NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.


AmAr i ran Rpal FstatR InvRstmsnts Nn P, I I C, 700 Rriggp RnaH, Flk Grnvp VillagR, II mCiViJ i n n % hPHpfirlal IntArpgt

SECTION 111 ~ BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


[ ] Yes M No



The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature of the relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll,

"Lobbyist" m.eans any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13



(Add shcet.s if necessary)

1X1 Check here if the Disclosing Party has not retained, nor expects lo retain, any such persons or entities.





[ J Yes M No [ ] No person directly or indirectly owns 10% or more ofthe Disclosing Party.


[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consiiU for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Apphcant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article 1 is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Apphcant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II .B.l . of this EDS: ' ;



c. are not presently indicted for, or criminally or civiUy charged by, a governmental entity (federal, state or local) with committing any of the offenses set forth in clause B.2.b. of this Section V;




• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in connection with the Matter, including but not hmited to all persons or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: contrpls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of mterests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affihated Entity or any


Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of cither the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery ov attempting to bribe, a public officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;





5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following hsts maintained by the Office of Foreign Assets Control of the U.S. Department of the Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List,



Page 6 of 13


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"). N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also list the name of the City recipient, N/A



I

[ ] is ^] is not



"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code, We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary): N/A

Page 7 of 13



Any words or terms that arc defined in Chapter 2-156 of the Municipal Code have the same meanings when used in this Part D.

1. In accordance with Section 2-156-110 of the Municipal Code: Does any official or employee of the City have,a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes M No

NOTE; If you checked "Yes" to Item D.l. , proceed to Items D.2. and D.3. 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 tho City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D,


[JYes MNo

3. If you checked "Yes" to Item D.l. , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest;


4. The Displosing Party further certifies that no prohibited financial interest in the Matter will be acquired by ny City official or employee.


Please check either 1. or 2. below. If-thc Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

Page 8 of 13




SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VL If the Matter Is not federally funded, proceed to Section VII. For purposes of this Section VI, tax credits allocated by the City and proceeds of debt obligations of the City arc not federal funding.' :

A. CERTIFICATION REGARDING LOBBYING .


(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or entities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)


Page 9 of 13

3. The Disclosing Party will submit an updated certification al the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that cither: (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501 (c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. If the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make .such certifications promptly available to the City upon request.


I

If the Matter is federally funded, federal regulations require the Apphcant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.


[JYes [ j N o



[]Yes [JNo

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract CompUanee Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No


[ J Yes [ ] No


Page 10 of 13

SECTION V n - ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE

The Disclosing Party understands and agrees that: ',

A. The certifications, disclosures, and acknowledgrrients contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement, City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.


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 Parly's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City, 'Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the pubhc on its Internet site and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibihty must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code,

The Disclosing Party represents and warrants that: • i

Page 11 of 13

6

F. 1. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affiliated Entities delinquent in paying any fine, fee, lax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 I f the Disclosing Party is the Applicant, the Djsclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F. l . and F.2. above and wil l nol, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any ofthe items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if apphcable) are ti-ue, accurate and complete as of the date furnished to the City.

First American Bank, not personally, but as Trustee U/T/A dated April 6, 2009 and known as Trust number 1-09-111 (Print or type name of Disclosing Party)

By: P(jLuM/V (Sign here)


Senior- Vice Pres ident (Print or type title of person signing)

Exoneration provision restricting any lisbility of First American Bank attached hereto is expressly made a part hereof.

Signed and swom to before me on (date) a' / { / ^ / ^ ( f County^ Illinois (state).

Commission exp

DM2\6056296.1

ires: f((/o/Ct IS-

Notary Public.

Page 12 of 13

QFRCIM.SEAL RdSMMEOUPASS

NOTAWWBUC-CTATEOFiaiMOIS MY COMMSSJON EXPIRES:! 1/04/18


APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICULS AND DEPARTMENT HEADS


Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "famihal relationship" with any elected city official or department head. A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Apphcable Party" means (1) all executive officers ofthe Disclosing Party hsted in Section ILB.l.a., if the Disclosing Party is a corporation; all partners of tlie Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners ofthe Disclosing Party, if the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, i f the Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ ] Yes ^ ] No

If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a famihal relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity wliich has only nn indirect ownership interest in the Applicant.

1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code? 1

[ .JYes [X]No


•[ JYes ( JNo [XJ Not Applicable

3. If yes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, TPIE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

Exculpation of Trustee

It is expressly understood and agreed by and between the parties hereto, anything herein to the contrary notwithstanding, that each and all ofthe warranties, indemnities, representations, covenants, undertakings and agreements herein made on the part of the Trustee, while in form purporting to be the warranties, indemnities, representations, covenants, undertakings and agreements of First American Bank as said Trustee, are nevertheless each and every one of them, made and intended not as personal warranties, indemnities, representations, covenants, undertakings and agreements by First American Bank or any of its directors, officers, employees, or shareholders or for the purpose or with the intention of binding First American Bank or any of its directors, officers, employees, or shareholders personally but are made and intended for the purpose of binding only that portion of the trust property specifically described herein, and this instrument is executed and delivered by First American Bank not in its own right, but solely in the exercise of the powers conferred upon it as such Trustee, and no personal liability or personal responsibility is assumed by nor shall at any time be asserted or enforceable by any person against First American Bank or any of its directors, officers, employees, or shareholders on account of this instrument or on account of any warranty, indemnity, representation, covenant, undertaking or agreement of the Trustee in this instrument, all such personal liability, i f any, being expressly waived and released and any recovery therefor being limited to the property hereby conveyed and the enforcement of remedies under the documents and instruments creating, securing, or otherwise governing the obligations secured by this instrument; provided however, this clause shall not impair the enforceability or adversely affect the availability of any rights that may otherwise be available to Mortgagee or the obligations of any co-signer, endorser, or guarantor of the obligations secured by this instrument; and provided further, that the foregoing limitations on personal liability shall not impair the validity of the indebtedness secured by Mortgagee's collateral or the lien or security interest on the collateral or the right of Mortgagee as mortgagee or secured party to foreclose and/or enforce rights against the collateral after default by the Mortgagor. Subject to the foregoing, the warranties, indemnities, representations, covenants, undertakings and agreements herein made on the part of the Trustee are made for the sole benefit of Mortgagee, and no other person or persons, other that Mortgagee's successors or permitted assigns, shall have any benefits, rights, or remedies by reason of such warranties, indemnities, representations, covenants, undertakings and agreements herein made on the part of the Trustee. Nothing herein shall be deemed to be a waiver of any right which Mortgagee may have under sections 506(a), 506(b), 1111 (b) or any other provision of the Bankruptcy Reform Act of 1978, as at any time amended or reinstated, to file a claim for the full amount of the debt owing to Mortgagee in the event Mortgagor or its beneficiary should become the subject of a petition for bankruptcy or reorganization or to require that all collateral shall continue to secure all of the indebtedness owing to Mortgagee in accordance with the documents and instruments creating, securing, or otherwise governing the obligations secured by this instrument.


AND AFFIDAVIT

SECTION I ~ GENERAL LNFORMATION

A. Legal name of the Disclosing Party submitting this EDS, Include'd/b/a/ if applicable;

American Real Estate Investments No, 2, LLC

Check ONE of the following three boxes;

Indicate whether the Disclosing Party submitting this BDS is: 1. [ J the

OR • • 2. [xl a legal entity holding a direct or indirect interest in. the Property Owner. State the.legal name of thfe

Applicant in which the Disclosing Party holds an interest; First American Bank, not personally, but aa . OR Trustee U/T/A dated April 6,2009 and known aa Trust No. 1-09-lU

3. [J alegalentity with a right of control (see Section ILB.L) State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 7nn Riissfi R^H nk nrmn yiiiaQft, iiiinnte Roop?

C. Telephone; 847-586-2583 Fax; 847-586-2583 Eftail; [email protected]

D. Name of contact person; Donald Roubitchek ^ _



Planned Development Application for 920-1006 South IVIIchlgan Avenue and 1011-1015 South Wabash.

G. Which City agency or department is requesting this BDS? Department of Planning and Development

If the Matter is a contract being handled by the City's Department of Procurement Services, please complete the following;


Ver. 01-01-n Page 1 of 13 DM2\6066331.1



1. Indicate the nature ofthe Disclosing Party: , Person , , J Limited liability company Publicly registered business corporation [ J Limited liability partnership Privately held business corporation [ J Joint venture Sole proprietorship [ J Not-for-profit corporation General partnership (Is the not-for-profit corporation also a 501(c)(3))? Limited partnership [ J Yes [ J No Trust [ J Other (please specify)


Illinois


[ J Yes [ J No [X] N/A

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY: : j

1. List below the full names and titles of all executive officers and all directors ofthe entity. NOTE: For not-for-profit corporatiojis, also list below all members, i f any, which are legal entities. I f there are no such members, write "no inembers." For trusts, estates or other similar entities, list below the legal titleholder(s).

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 hsted below must submit an EDS on its own behalf.

Name Title

_Jirst American.Bank , Sole Member and Managfir


I Page 2 of 13

interest of a member or manager in a hmited hability company, or interest of a beneficiary of a trust, estate or other similar entity. 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.


Flr.qt AmRfinan Rank 16.^0 I mil.'; Avp.., Flk firnvft Village, II Rpnn/ 100% a.q snle mpmhRr

SECTION III ~ BUSINESS RELATIONSHIPS WITH C I T Y E L E C T E D OFF^: iALS

Has the Disclosing Party had a "business relationship," as defined in Chapter 2-156 ofthe Municipal Code, with any City elected official in the 12 months before the date this EDS is signed?,

[ J Yes M No






Page 3 of 13





Ix] Check here i f the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V - CERTIFICATIONS,

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE I 1



[ J Yes No [ J No person direptly or indirectly owns 10% or more ofthe Disclosing Party.


[ J Yes [ J No

B. FURTHER CERTIFICATIONS ,

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: ;If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year comphance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, 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:


b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civiljudgment rendered against them in connection with: obtaining, attempting to obtain, or performing a pubhc (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;



e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any crimiiial or civil action, incliiding actions conceming environmental violations, instituted by the City or by the federal governinent, any state, or any other unit of local government.




Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as tlie ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; | • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Cbntractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affihated Entity of either the Disclosing Party or any Contractor nor any Agents haye, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or,Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubhc officer or employee ofthe City, the State of Illinois, or any agency ofthe federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;




4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offeijise of bid-rigging or bid-rotating.

5. Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security of the U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.


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:

MA

Page 6 of 13


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"). N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general pubhc, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also Ust the name of the City recipient. N/A



[ J is M is not



"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 l become, a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City,"

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as' defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13





[ J Yes ^ No

NOTE: If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D.L, proceed to PartE.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a fmancial interest within the meaning of this Part D.


[JYes . MNo

3. If you checked "Yes" to Item D.L, provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:

Name Business Address i Nature of Interest




Page 8 of 13


X ^1. The Disclosing Party verifies that the Disclosing Party has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance pohcies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records.



NOTE: I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING , ! . I


(If no explanation appears or begins on the Hnes 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.)


Page 9 of 13



5. I f the Disclosing Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A.L through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.




[ J Yes [ J No

If "Yes," answer the three questions below: ,'


[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract CompHance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ J Yes [ J No .


[JYes [JNo


Page 10 of 13

SECTION Vl l ~ ACKNOWLEDGMENTS, CONTRACT INCORPORATION, COMPLIANCE, PENALTIES, DISCLOSURE


A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Apphcant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party understands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.



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 decUning to allow the Disclosing Party to participate in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site' and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and release's any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. 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.


Page 11 of 13


F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List.System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l . and F.2. above and will not, without the prior written consent ofthe City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide truthful certifications.

NOTE: If the Disclosing Party cannot certify as to any of the items in F.L, F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION


American Real Estate Investments No. 2, LLC

(Print or type name of Disclosing Parly) F i r s t American Bank, i t s Manager

(Sign here)

Frederick M. Snow (Print or type name of person signing)

Executive Vice President and General Counsel


Signed and sworn to before me on (date) ^ l ^ li f ^<! - ^ A x ^ ^ - ^

Notary Public.

Commission expires:

Page 12 of 13 DM2\6056331.1


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Paitner thereof currently has a "familial relationship" with any elected city official or department head. A "famihal relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partner or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers ofthe Disclosing Party hsted in Section H.B.l.a., i f the Disclosing Party is a corporation; all partners ofthe Disclosing Party, i f the Disclosing Party is a general partaership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a hmited partnership; all managers, managing members and members of the Disclosing Party, if the Disclosing Party is a limited habihty company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. ;"Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.


[ J Yes M No

If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such faniilial relationship.

Page 1'3 of 13


APPENDIX B


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). I t is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code? !

t <

[ ij Yes ! [XJiNo


[ J Y e s [ J N o [X] Not Applicable


FILLING OUT THIS APPENDIX B CONSTITUTES ACKJÔWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATIOISf MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.


AND AFFIDAVIT


A. Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable;

First American Bank


Indicate whether tho Disclosing Party submitting this EDS is: 1. [ ] the

OR American Real Estate Investments No. 2, LLC. 2. [x] a legal entity holding a direct or indirect lateiest in the / State the legal name ofthe

Applicant ui which the Disclosing Party holds an interest; First American Bank, not personally, buTas Qg_ Tmstee U/T/A dated April 6,2009 and Icnown as Trast No. 1-09-111

3. [ ] alegalentity with a right of control (see Section II.B.1.) State the legal name of the entity in which the Disclosing Party holds aright of control:

B, B usiness address ofthe Disclosing Party; iRsn i r>iii«t Avpri'iB, Omvp Village, ininriis ^p,

C. Telephone; (847) 586-2583 Pax; -(847) 586-2583 : Email; .droubitchek(5),firstambank.com

D. Name of contact person: Donald Roubitchek ,


F, Brief description, of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, if apphcable):

Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 Soutii Wabash.

G. Which City agency or department is requesting this EDS? Department of Planning and Development /

If the Matter is a contract being handled by the City's Depaitment of Piooiurement Services, please complete the following;

Specification # and Contract#

Ver. 01-01-12 Page 1 of 13 DM2\6056406,1


A. NATURE OF THE DISCLOSING, PARTY

1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited liabihty company [ ] Publicly registered business corporation [ ] Limited liability partnership EK] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust , [ ] Other (please specify)


hnois

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of IlHnois as a foreign entity?

[]Yes []No M'N/A


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).

I f the entity is a general partnership, limited partnership, Hmited Habihty company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each lejgal entity listed below,must submit an EDS on its own behalf.

Name , ' Title .qflfi attached Appendix C for li.st nf directors anri exPiniitivR nffirF-rR


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. 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 apphcant which is reasonably intended to achieve full disclosure.


Firat American Rank Onrpnratinn 1RRn I niil.q Avft.. F]\c P,rn\iP. Village, II Rnnn?

SECTION HI - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


[ ] Yes KI No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship (s);



"Lobbyist" means any person or entity who undertakes to influence any legislative or adihinistrative action on behalf of any person or entity other than; (1) a not-for-profit entity, on an unpaid basis, or (2) himself. "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13

Name (indicate whetlier Business-retained or anticipated Address to be retained)




]X\ Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.



' < r I

Under Muniqipal Code Section 2-92-415, substantial owners of business entities that contract with the City must remain in compHance with their child support obligations throughout the contract's term.

Has any person,who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obHgations by any Illinois court of competent jurisdiction?

[JYes ^ No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.


[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1 -23, Article I ("Article r')(which the Apphcant should consult for defined terms (e.g., "doing business") and legal requirements), i f the Disclosing Party submitting this EDS is the Apphcant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I appHes to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, 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 ineHgible or voluntarily excluded from any transactions by any federal, state or local unit of government;





3. The certifications in subparts 3, 4 and 5 concern: '



Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affihated Entity or any

other official, agent or employee of the Disclosing Party, any Coiitractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affiliated Entity of a Contractor during the five years before the date pf such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubHc officer or empl|0yee of the City, the State of IlHnois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;


c. made an admission of such conduct described in a. or b. above that is a matter of record, but have not been prosecuted for stich conduct; or





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 niust explain below: N/A

Page 6 of 13



9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete Hst of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything made generally available to City employees or to the general pubHc, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift Hsted below, please also list the name ofthe City recipient. N/A



is [ ] is not



"We are not and will not become a predatory lender as defined in Chapter 2-32 of the Municipal Code. We further pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiHate of a predatory lender may result in the loss of the privilege of doing business with the City."

If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): N/A

Page7 of 13




1. In accordance with Section 2-.156-110 of the Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ]Yes MNo

NOTE: 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 spld pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[ ] Yes [X] No

3. I f you checked "Yes" to Item D.l . , provide the names and business addresses ofthe City officials or employees having such interest and identify the namre of such interest:





Page 8 of 13



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;


NOTE: If the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING ,

I


(If no explanation appears or begins on the lines above, or if the letters "NA" or i f the word "None" appear, it will be conclusively presumed that the Disclosing Party means that NO persons or enfities registered under the Lobbying Disclosure Act of 1995 have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter.)

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l , above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by apphcable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986; or (H) it is an organization described in section 501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities".

5. If the Disclosing Party is the Applicant, the Disclosing .Party must obtain certifications equal in form and substance to paragraphs A . l . through A.4. above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make .such certifications promptly available to the City upon request,




[ ] Yes [ ] No .


1. Have you developed and do you have on file affirmafive acfion programs pursuant to applicable federal regulations? (See 41 CFR Part 60-2.)

. [ ] Yes [ ] No


[ ] Yes [ ] No


[]Yes [ ] N o

I f 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 '





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 parficipation in the Matter and/or decHning to allow the Disclosing Party to participate in other transacfions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the public on its Internet site'and/or upon request. Some or all ofthe information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must stipplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE: With respect to Matters subject to Arficle I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT 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.


Page 11 of 13 •n -.. •\. •\M*f.>'i~w' <

F.l. The Disclosing Party is not definquent in the payment of any tax administered by the IHinois Department of Revenue, nor are the Disclosing Party or its Affihated Enfities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, all water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affiliated Entities will not use, nor permit their subcontractors to use, any facihty hsted by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F,3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certificafions equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certificafions or that the Disclosing Party has reason to believe has not provided or cannot provide truthful cerfifications.

NOTE: If the Disclosing Party cannot cerfify as to any of the items in F, 1., F.2. or F.3. above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that aH certificafions and statements contained in this EDS and Appendix A (if applicable) are trae, accurate and complete as of the date furnished to the City.

First American Bank • (Print or type name of Disclosing Party)

(Sign here)


Executive Vice President and General Counsel (Print or type fitle of person signing)

Signed and sworn to before me on (date) at C f i x ^ County, IHinois (state)

Notary PubHc.

Commission expires:

DM2\6056406.1 Page 12 of 13


APPENDIX A



Under Municipal Code Secfion 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "famiHal relationship" with any elected city official or department head. A "famihal relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner therepf is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partaer or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, motlier-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister.

"Applicable Party" means (1) all executive officers of the Disclosing Party Hsted in Section II.B.l.a., i f the Disclosing Party is a corporation; all partoers of the Disclosing Party, if the Disclosing Party is a general partnership; all general partners and limited partners of the Disclosing Party, if the Disclosing Party is a limited partaership; all managers, managing members and members ofthe Disclosing Party, i f the Disclosing Party is a limited Habihty company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes [ ] No

If yes, please identify below (1) the name and fitle of such person, (2) the name of the legal entity to which such person is connected; (3) file name and tifie of the elected city official or depaitment head to whom such person has a familial relationship, and (4) the precise nature of such famiHal relationship.

Page 13 of 13

CITY OF CinCAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT

APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTLFICATION


1. Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code? !

[ |]Yes I [X]:No I •

2. I f the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuantto Section 2-92-416 ofthe Municipal Code?

[ ]Yes [ ]No [X] Not Applicable

I f yes to (1) or (2) above, please identify below the name ofthe person or legal entity identified as a building code scofflaw or problem landlord and the address ofthe building or buildings to which the pertinent code violations apply.


Directors:

Martin J. Carmody Michael F. Kashtan William H. Kerdyk James M. Lynch Frederick M. Snow John B. Ward Thomas E. Wells, IV

City of Chicago Economic Disclosure Statement and Affidavit

Appendix C First American Bank

Executive Officers: Tifie:

Martin J. Carmody Gene M. Coots Brian T. Hagan Robert L. Horsman Kim M. Kohon Noel R. Levasseur James M. Lynch Eduardo Monteagudo Jane Nagel John L. Olsen Linda Overbey Donald Roubitchek Frederick M. Snow Adelbert Spaan John B.Ward James Wargas Thomas E. Wells, IV Lawrence Zydowsky

Senior Executive Vice President Executive Vice President Executive Vice President Executive Vice President Executive Vice Prissident Execufive Vice President Vice Chairman Executive Vice President Executive Vice President Executive Vice President Executive Vice President Executive Vice Prpsident Executive Vice President & General Counsel Executive Vice President President Executive Vice President , Chairman, Chief Executive Officer Executive Vice President

DM2\6085508.I


AND AFFIDAVIT

SECTION I " GENERAL INFORMATION

A, Legal n me of the Disclosing Paity suhmitting this EDS, Include d/b/a/ if appUoablQi

First American Bank Corpoiation

Check OW ol the foUowthg three boxes;

Ittdicatc whether the DlBoloaJng Party submitthg thl.s EDS is; 1. [ ] the

OR , , First American Bank 2. 1x1 a Icgftl entity holding a direct 01 indirect itttorest in the/ State the legal name of the

Applioant m wiioh the Disclosing Paity holds m interest: First American Bank, not pBrsonally, bufss Q TtmtcB U/T/A dated Ajrii 6,2009 nnd Jmomi as Tmt No, 1-09-111

3. [ ] e legal entity with a right of control (see Scotiou n.B,L) State the legal name ofthe entity in which tho Disclosing party holds a tight of, control;, ,

B, Bugimes.s address of the Disolqsing Parly; .IRRO I puia AMjPUft, FIV OrnvR vinapB, illlnniB RQ

C, Telephone; ;(647) 586-2585 Fax; -(847 686-2583 .. Emaih [email protected]

D. Nanio of contact persQii; Donald Roubitchek ^

B. Federal Employer Identification No. (if you have one); . ^

F, Brief desoription of oontraot, transaction or other undertaking (referred to below as the'"Mattex") to v/hich this EDS pertains. (InoMa projeot numhci and looatioii of property, if applicable);


G, Which City agency or department ia requesting thia BDS? Department of Planning and Developmsnt

I f the Matter is a oontraot being handled by the City's Depaitment of Procurement ServleeB, please complete the following;

Speeifleation # and Coatiaot # •

Vcr. 01-01-12 Pago 1 of 13 DM2\6Q97936.1

SECTION I I - DISCLOSURE OF OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited hability company [ ] Publicly registered business corporation [ ] Limited liability partnership ^ Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partaership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No [ ] Trust [ ] Other (please specify)

2, For legal entities, the state (or foreign country) of incorporation or organization, if applicable:

Delavvare


_ _ Yes K N o . [ ] N/A


1. List below the full nam s and titles of all executive officers and all directors ofthe entity. NOTE; For not-for-profit corporations, also list below all members, if any, which are legal entities, I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s)'.

I f the entity is a general partnership, hmited partnership, limited hability company, limited liabihty partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of tihe Disclosing Party. NOTE: Each legal entity listed below must submit an EDS on its own behalf.

Name Title Saa attahhRd Appfinrilx O for li.qt nf filrftntnr.s and HXRoiirivn nffinRr.q..

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% of the Disclosing Party. Examples of such an interest include shares in a coiporation, partnership interest in a partnership or joint venture.

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a tmst, estate or other similar entity. I f none, state "None." NOTE: Pursuant to Section 2-154-030 of the Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.

Name Business Address Percentage interest in the Disclosing Party

Fir.qf AmRrican Rank nnrpnratinn IR.i^n I niil.<; Aw FJk Rrtwa V/illag<> II Rnnn? ^.65% Einployee Stock Ownership Plan

; Carolyn C. Wells Trust under agreement dated 4/7/88 1650 Louis Ave., Elk Grove Village, IL 60007 12.39%

SECTION III - BUSINESS RELATIONSHIPS WITH CITY ELECTED OFFICIALS


[]Yes MNo

I f yes, please identify below the name(s) of such City elected official(s) and describe such .• relationship(s); i



"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid hasis, or (2) himself. "Lobhyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.

If the Disclosing Party is uncertaia whether a disclosure is required under this Section, the Disclosing Party must either ask the City whether disclosure is required or make the disclosure.

Page 3 of 13


Relationship to Disclosing Party (subcontractor, attomey, lobbyist, etc.)







1

Has any person who directly or indirectly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obhgafions by any Illinois court of competent jurisdiction?

[JYes M No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

If "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in comphance with that agreement?

[ ] Yes [ ] No


1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article r')(which the Apphcant should consult for defined terms (e.g., "doing business") and legal requirements), if the Disclosing Party submitting this EDS is the Applicant and is doing business with the City, then the Disclosing Party certifies as follows: (i) neither the Applicant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; arid (ii) the Applicant understands and acknowledges that compliance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section II.B.l . of this EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from any transactions by any federal, state or local unit of govemmenti



d. have not, within a five-year period preceding the date of this EDS, had one or more pubhc transactions (federal, state or local) terminated for cause or default; and

e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found liable in a civil proceeding, or in any criminal or civil action, including actions conceming environmental violations, instituted by the City or by the federal government, any state, or any other unit of local government.


• the Disclosing Party; • any "Contractor" (meaning any contractor or subcontractor used by the Disclosmg Party in


Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity, Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the Ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineUgible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee ofthe Disclosing Party, any Contractor or any Affihated Entity, acting pursuant to the direction or authorization of a responsible official of the Disclosiag Party, any Contractor or any Affihated Entity (collectively "Agents").

Pages of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affihated Entity, or an Affihated Entity of a Contractor duriag the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubhc officer or employee of the City, the State of Illinois, or any agency of the federal government or of any state or local government in the United States of America, in that officer's or employee's official capacity;

b. agreed or colluded with other bidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospeqtive bidders, in restraint of freedom competition by agreement to bid a fixed price or otherwise; or '

c. made an admission of such cpnduct described in a. or b. above that is a matter of record, but have not been prosecuted for such conduct; or


4. Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1} bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotating in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigguig or bid-rotating.

5. . Neither' the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.


7. If the Disclosing Party is unable to certify to any of the above statements in this Part B (Further Certifications), the Disclosing Party,must explain below: N/A

Page 6 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements,

8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all current employees of the Disclosing Party who were, at any time during the 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"), N/A

9, To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of tbis EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include; (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift hsted below, please also list the name ofthe City recipient, N/A


1, The Disclosing Party certifies that the Disclosmg Party (check one)

l;] is is not


2, If the Disclosing Party IS a financial institution, then the Disclosing Party pledges:

"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affihates is, and none of them will become, a predatory lender as defined in Chapter 2-32 pf the Municipal Code. We understand that becoming a predatory lender or becoming an affihate of a predatory lender may result in the loss ofthe privilege of doing business with the City,"

If the Pisclosing Party is unable to make this pledge because it or any of its affihates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 of the Municipal Code, explain here (attach additional pages if necessary); N/A

Page 7 of 13

If the letters "NA," the word "None," or no response appears on the lines above, it will be conclusively presumed that the Disclosing Party certified to the above statements,



1, In accordance with Section 2-156-110 ofthe Municipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes M No

NOTE: If you checked "Yes" to Item D,l. , proceed to Items D.2, and D,3. 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.


[ ] Yes [X] No

3, If you checked "Yes" to Item D.l, , provide the names and business addresses of the City officials or employees having such interest and identify the nature of such interest:




Please check either 1, or 2. below. If the Disclosing Party checks 2., the Disclosing Party must disclose below or in an attachment to this EDS all information required by paragraph 2. Failure to

. I Pages of 13

comply with these disclosure requirements may make any contract entered into with the City ia connection with the Matter voidable by the City.

X 1. The Disclosing Party verifies that the Disclosing Parly has searched any and all records of the Disclosing Party and any and all predecessor entities regarding records of investments or profits from slavery or slaveholder insurance policies during the slavery era (including insurance policies issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and the Disclosing Party has found no such records,

2. The Disclpsing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or profits from slavery or slaveholder insurance pohcies. The Disclosing Party verifies that the followmg constitutes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE; I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VII. For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING .

1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter; (Add sheets if necessary):

(If no explanation appears or begins on the lines above, or if the letters "NA" or if the word "None" appear, it 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 hsted in Paragraph A . l . above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by apphcable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13


4. The Disclosing Party certifies that either; (i) it is not an organization described in section 501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities",

5. If the Discloshig Party is the Applicant, the Disclosing Party must obtain certifications equal in form and substance to paragraphs A . l , through A.4, above from all subcontractors before it awards any subcontract and the Disclosing Party must maintain all such subcontractors' certifications for the duration of the Matter and must make such certifications promptly available to the City upon request.

B, CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY



[ ] Yes [ ] No

If "Yes," answer the three questions below;

1. Have you developed and do you have on file affirmative action programs pursuant to apphcable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No


[ ] 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


A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any contract or other agreement between the Applicant and the City in connection with the Matter, whether procurement. City assistance, or other City action, and are material inducements to the City's execution of any contract or taking other action with respect to the Matter. The Disclosing Party imderstands that it must comply with all statutes, ordinances, and regulations on which this EDS is based.

B. The City's Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties arid obligations on persons or entities seeking City contracts, work, business, or transactions. The full text of these ordinances and a training program is available on line at www.citvofchieaRo.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660, The Disclosing Party must comply fully with the applicable ordinances.

C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate,in other transactions with the City. Remedies at law for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the pubhc on its Internet site ahd/or upon request. Some oi aU of the infonnation provided on this EDS and ahy attachments to this EDS may be made available to the pubhc on the Intemet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any infoimation submitted in this EDS,

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing tarty must update this EDS as the contract requires, NOTE: With respect to Matters subject to Article I of Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the information provided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code,


Page 11 of 13

F.l, The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department'of Revenue, nor are the Disclosing Party or its Affihated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not limited to, aU water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F.2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U. S. General Services Administration.

F.3 If the Disclosing Party is the Apphcant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l, and F.2, above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide tmthfhl certifications,

NOTE: If the Disclosing Party cannot certify as to any ofthe items in F,l., F.2. or F,3, above, an explanatory statement must be attached to this EDS.

CERTIFICATION

Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contaiped in this EDS and Appendix A (if applicable) are tme, accurate and complete as ofthe date furnished to the City,

First American Bank Corporation ,,, (Print or type name of Disclosing Party)

By; (Sign here)


Executive Vice President and General Counsel (Print or type titie of person signmg)

Signed and sworn to before me on (date) at O i S t ^ ^ County, nifaoia (state),

y^^^^^^^y? Notary Public.

Commission expires: ( ^ C ' ' ^ ' ' ^ f \ OFFICIAL SEAL J JAMES M BERTON


APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICLAJLS AND DEPARTMENT HEADS

This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It Is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with any elected city official or department head, A "famihal relationship" exists if, as ofthe date this EDS is signed, the Disclosmg Party or any "Apphcable Party" or any Spouse or Domestic Partaer thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or . domestic partaer or as any of the foUowing, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister,

"Applicable Party" means (1) ah executive officers o 'the Disclosing Party hsted in Section I[.B.l.a., i f the Disclosing Party is a corporation; all paxtaers ofthe Disclosing Party, if the Disclosing Party is a general partaership; all general partners and Iknited "partners of the Disclosing Party, if the Disclosing Party is a limited partaership; aU managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party, "Principal officers" means the president, chief

• operating officer, executive director, 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 "famiUal relationship" with an elected city official or department head?

[ ] Yes M No

If yes, please identify below (1) the name and tide of such person, (2),the name ofthe legal entity to which such person is connected; (3) the name and titie ofthe elected city official or department head to whom such person has a familial relationship, and (4) the precise natare of such famihal relationship.

Page 13 of 13


APPENDIXB


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity •which has a direct ownership interest in the Applicant exceeding 7,5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

1. pursuant to Municipal Cpde Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 of the Municipal Code?

[ ]Yes [X]No


[ ]Yes [ ]No [X] Not Applicable

If yes to (1) or (2) above, please identify below the name ofthe person or legal entity identified as a building code scofflaw or problem landlord and the address of tlie building or buildings to which the pertinent code violations apply,

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OP, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

Directors:

William Y. Bogle Martin J. Carmody Caren M. Furbeyre Michael F. Kashtan William H. Kerdyk .lames M, Lynch Richard R, Matthias Adelbert P,C. Spaan John B. Ward Thomas E. Wells, IV

City of Chicago Economic Disclosure Statement and Affidavit

Appendix C First American Bank Corporation

Executive Officers: Titie:

Martin J. Carmody •James M, Lynch Donald Roubitchek Frederick M. Snow John B. Ward Thomas E. Wells, IV

Senior Executive Vice President President Executive Vice President Executive Vice President & General Counsel Vice Chairman Chairman, Chief Executive Officer

DM2\60!)7907,1


ANJ) AFFIDAVIT


A, Legal name of tho Disclosing Party submitting this EDS. Include d/b/a/ if applicable;

First American Bank Corporation Employee Stock Ownership Plan

Check ONE ofthe followiiig three boxes;

Indicate whether the Disclosing Party submittmg this EDS is; 1. [ ] the

OR • Coiporation 2. ^ 8 l^gal entity holding a direct or indirect interest in the .First American Bank/ State the legal namo of the

Apphpant in which the Disclosing Party holds an interest; First Anrierlcan Bank, not personally, but as Qg Tnistee U/T/A dated Apiil 6,2009 and kEOwn aa Trast No, i-09rl 11

3. [ ] a legal entity with aright of control (see Section n,B,l.) State the legal name of the entity in which the Diselosing Party holds a right of control;

B, Business address of the Disclosmg Party: ^mn L nnis AvBnua, Rk nrfivg viiiflgp., iiiinnia finiifl

C. Telephono; (847) 586-8075 \ Pax: ,(847) 586-8075 \ Email: [email protected] j

D. Name of contact poison; Jane Nagel i

E. Federal Employer Identification No, (if you have- one); ^

F, Brief description of contract, transaction or other undertaking (referred to below as the "Matter") to which this EDS pertains. (Include project number and location of property, i f applicable):

Planned Development Application for 920-1006 South Michigan Avenue and 1011-1015 South Wabash, ^



Specification # and Contract if ,

Vcr, 01-01-12 Page 1 of 13 DM2\6087748,1 :

SECTION II -r DISCLOSURE OF OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party: ] Person [ ] Limited liability company ] Publicly registered business corporation [ ] Limited liability partnership ] Privately held business corporation [ ] Joint venture ] Sole proprietorship [ ] Not-for-profit corporation ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? ] Limited partnership [ ] Yes [ ] No ] Trust Other (please specify)

Employee Stock Ownership Plan


Illinois


[ ] Yes [ ] No N/A


1. List below the full names and titles of all executive officers and all directors ofthe entity. NOTE: For not-for-profit corporations, also list below all members, i f any, which are legal entities. I f there are no such members, write "no members." For trusts, estates or other similar entities, list below the legal titleholder(s).

If the entity is a general partnership, limited partnership, limited hability company, limited liability partnership or joint venture, list below the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management ofthe Disclosing Party. NOTE: Each legal enfity listed below, must submit an EDS on its own behalf.

Name Title

See attached Appendix C for list of mfimhsrs of Admlnistrativfi CnrnmittfiR..


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.


• InhnWard IfiSO 1 mils A V R , Flk GrnvP. VillaqB, 11 Rni1R 1.4.07% James Lynch 1650 Louis Ave., Elk Grove Village, IL 60118 12.46%



[ ] Yes M No


SECTION IV -- DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney, lobbyist, accountant, consultant and any other person or entity whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll.



Page 3 of 13





Check here if the Disclosing Party has not retained, nor expects to retain, any such persons or entities.



Under Municipal Code Section 2-92-415, substantial owners of business entities that contiact with the City must rqmain in compliance with their child support obligations throughout the contract's term.


[ ] Yes M 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 comphance with that agreement?

[ ] Yes [ ] No


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 Apphcant nor any controlling person is currenfiy indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compHance with Article I is a continuing requirement for doing business with the City. NOTE: I f Article I applies to the Applicant, the permanent compliance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I .B. l . of this EDS:

a. are not presently debarred, suspended, proposed for debarment, declared ineHgible or voluntarily excluded from any transactions by any federal, state or local unit of government;


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;


e. have not, within a five-year period preceding the date of this EDS, been convicted, adjudged guilty, or found Hable in a civil proceeding, or in any criminal or civil action, including actions concerning environmental violations, instituted by the City or by the federal govemment, any state, or any other unit of local govemment,


• the Disclosing Party; ' • any "Contractor" (meaning any contractor or subcontractor used by the Disclosing Party in

connection with the Matter, including but not limited to all persons or legal entities disclosed under, Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affihated Entity" (meaning a person or entity that, directly or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation: interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or sta!te or local government, including the City, using substantially the same management, ownership, or principals as the ineHgible entity); with respect to Contractors, the term Affiliated Entity means a person or entity that directly or indirectly controls the Contractor, is controlled by it, or, with the Contractor, is under common control of another person or entity; • any responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee of the Disclosing Party, any Contractor or any Affihated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affihated Entity (collectively "Agents").

Page 5 of 13




c. made an admission of such conduct described in a, or b. above that is a matter of record, but have not been prosecuted forjsuch conduct; or


4, Neither the Disclosing Party, Affiliated Entity or Contractor, or any of their employees, officials, agents or partners, is barred from contracting with any unit of state or local government as a result of engaging in or being convicted of (1) bid-rigging in violation of 720 ILCS 5/33E-3; (2) bid-rotatmg in violation of 720 ILCS 5/33E-4; or (3) any similar offense of any state or of the United States of America that contains the same elements as the offense of bid-rigging or bid-rotating.

5, Neither the Disclosing Party nor any Affiliated Entity is listed on any of the following lists maintained by the Office of Foreign. Assets Control ofthe U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Endty List and the Debarred List.

6. The Disclosing Party understands and shall comply with the applicable requirements of Chapters 2-55 (Legislative Inspector General), 2-56 (Inspector General) and 2-156 (Govemmental Ethics) ofthe Municipal Code.


Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete Ust of all current employees ofthe Disclosing Party who were, at any time during the 12-month period preceding the execution date of this EDS, an employee, or elected or apipointed official, of the City of Chicago (if none, indicate with "N/A" or "none"). N/A

9. To the best ofthe Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general pubHc, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift Hsted below, please also Hst the name ofthe City recipient. N/A

C, CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1, The Disclosing Party certifies that the Disclosing Party (check one) '

[ ] is [x] is not



"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affiliates is, and none of them wiU become, a predatory lender as defined in Chapter 2-32 of the Municipal Code. We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss of the privilege of doing business with the City."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) of the Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages i f necessary): N/A

Page 7 of 13


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. .


[ ] Yes M No

NOTE: I f youichecked "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 sbld pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[JYes [x]No •

3. If you checked "Yes" to Item D. l . , provide the names and business addresses ofthe City officials or employees having such interest and identify the nature of such interest:


4. The Disclosing Party further certifies that no prohibited financial interest in the Matter wiU be acquired by any City official or employee.



. • Page 8 of 13



2. The Disclosing Party verifies that, as a result of conducting the search in step 1 above, the Disclosing Party has found records of investments or prpfits from slavery or slaveholder insurance policies. The Disclosiag Party verifies that the following constimtes full disclosure of all such records, including the names of any and all slaves or slaveholders described in those records:


NOTE: I f the Matter is federally funded, complete this Section VI . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section VI , tax credits allocated by the City and proceeds of debt obligations of the City are not federal funding.


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):



Page 9 of 13


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".



I i

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.


[ ] Yes [ ] No


1. Have you developed and do you have on file affirmative action programs pursuant to apphcable federal regulations? (See 41 CFR Part 60-2.)

[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Contract Comphance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No :

3. Have you participated in any previous contracts or subcontiacts subject to the equal opportunity clause?

. [ ] Yes [ ] No

If you checked "No" to question 1. or,2. above, please provide an explanation:

Page 10 of 13




B. The City's Governmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The fuU text of these ordinances and a tiaining program is available on line at www.citvofchicago.org/Ethics. and may also be obtained from the City's Board of Ethics, 740 N.

Sedgwick St., Suite 500, Chicago, IL 60610, (312) 744-9660. The Disclosing Party must comply fully with the apphcable ordinances.

C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contiact or other agreement in cormection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or decHning to allow the Disclosing Party to participate in other transactions with the City, Remedies at law for a false statement of material fact may include incarceration knd an award to the City of treble damages, : j

D. It is the City's policy to make this document available to the public on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the pubHc on the Internet, in response to a Freedom of Information Actrequest, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. 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.


Page 11 of 13

F. 1. The Disclosing Party is not dehnquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affihated Entities delinquent in paying any fine, fee, tax or other charge owed to the City. This includes, but is not hmited to, aU water charges, sewer charges, hcense fees, parking tickets, property taxes or sales taxes,

F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not use, nor permit their subcontractors to use, any facility listed by the U.S. E.P.A. on the federal Excluded Parties List System ("EPLS") maintained by the U, S, General Services Administration.

F,3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F,l, and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to believe has not provided or cannot provide tmthful certifications.

NOTE; If the Disclosing Party cannot certify as to any ofthe items in F.l,, F.2. or F.3. above, an explanatory statement must be attached to this EDS,

CERTIFICATION

Under penalty of perjury, the person signing below; (1) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf ofthe Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as ofthe date furnished to the City,

First American Bank Corporation Employee Stock Ownership Plaii

(Print or type name of Disclosing Paityj

(Print or type name of persbn signing)


Signed_and sworn to before me on (date at C £ ^ f ( County, ni'no's (state).

. Notary Pubhc,

Commission expires:

Page 12 of 13

OFFiCIAL SEAL JAMES M BERTON

NOTARY PUBLIC - STATE OF ILLINOIS MY COMMISSION EXPIRES 10./09/16


APPENDIX A


This Appendix is to be completed only by (a) the AppUcant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent. It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with any elected city official or department head, A "familial relationship" exists if, as ofthe date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partaer or as any of the following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, ôn-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister,

"Applicable Party" means (1) all executive officers ofthe Disclosing Party listed in Section H.B.l.a., i f the Disclosing Party is a corporation; aU partners of the Disclosing Party, i f the Disclosing Party is a general partaership; all general partners and limited partners of the Disclosing Party, i f the Disclosing Party is a limited partnership; all managers, managing members and members ofthe Disclosing Party, i f the Disclosing Party is a limited hability company; (2) all principal officers ofthe Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party, "Principal officers" means the president, chief operating officer, executive director, 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 Paitner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes |X] No

If yes, please identify below (1) the name and titie of such person, (2) the narne ofthe legal entity to which such person is connected; (3) the name and title of the elected city official or department head t^ whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Page 13 of 13


APPENDIX B


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Apphcant exceeding 7.5 percent (an "Owner"). It is not to be completed by any legal entity which has only an indirect ownership interest in the Applicant.

1, Pursuant to Municipal Code Section 2-154-010, is the Applicant or any Owner identified as a building code scofflaw or:problem landlord pursuant to Section 2-92-416 of the Municipal Code? i :

[ i ] Yes i I [X] No

2. I f the Applicant is a legal entity publicly traded on any exchange, is any officer or director of . the Applicant identified as a building code scofflaw or problem landlord pursuant to Section

2-92-416 ofthe Municipal Code?

[ ]Yes [. ]No [X] Not Applicable

Kyes to (1) or (2) above, please identify below the name of the person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT A N D AGREEMENT 'THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPRESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE CERTIFICATION MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

City of Chicago ' Economic Disclosure Statement and Affidavit

Appendix C First American Bank Corporation Employee Stock Ownership Plan

Administrative Committee Members: Titie:

Susan BerchioUi Jane Nagel Linda Overbey Lauren Baldwin Daniel O'Connor

Senior Vice President Executive Vice President Executive Vice President Vice President Vice President

DM2\6Q89023.1

CITYOFCHICAGO ECONOMIC DISCLOSURE STATEMENT

AND AFFIDAVIT


A, Legal name of the Disclosing Party submitting this EDS. Include d/b/a/ if applicable;

Carolyn C. Wells Trust under agreement dated 4/7/88

Check ONE ofthe foUowing three boxes;

Indicate whether the Disclosing Party submitting this EDS is; 1, [ ] file

OR Corporation 2, Ix] a legal entity holding a direct or indirect interest in the First American Bank./State the legal name of the

Applicant in which the Disclosmg Party holds an interest; First American Bank, not personally, but a's Q Trustee U/T/A dated April. 6,2009 and known as Trast No, 1-09-111

3, [ ] alegalentity with a right of control (see Section n.B.l.) State the legal name of the entity in which the Disclosing Party holds a right of control:

B, Business address ofthe Disclosmg Party; iR.gn i p.ii. Aw nim. p\]< nmvp viliF.gf>, iiiinnk finun

C, . Telephone: (847) 586-2586 Fax: (847) 586-2586 Email: [email protected]

D, Name of contact person: Thomas E. Wells IV

E, Federal Employer Identification No. (if you have one);

F. Brief description of contract, traasaction or other undertaking (referred to below as the "Mattei") to which this EDS pertains. (Include project number and location of property, if apphcable):


G. Which City agency or department is requestmg this EDS? Department of Planning and Development



Ver, 01-01-12 Page 1 of 13 DM2\6087749.1

SECTION II - DISCLOSURE OE OWNERSHIP INTERESTS


1. Indicate the nature of the Disclosing Party: [ ] Person [ ] Limited liabihty company [ ] Publicly registered business corporation [ ] Limited liabihty partnership [ ] Privately held business corporation [ ] Joint venture [ ] Sole proprietorship [ ] Not-for-profit corporation [ ] General partnership (Is the not-for-profit corporation also a 501(c)(3))? [ ] Limited partnership [ ] Yes [ ] No EK] Trust , [ ] pther (please specify)


Illinois

3. For legal entities not organized in the State of Illinois: Has the organization registered to do business in the State of IlHnois as a foreign entity?

[JYes [ j N o • [j^N/A


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 belovv the name and title of each general partner, managing member, manager or any other person or entity that controls the day-to-day management of the Disclosing Party. NOTE: Each legal entity Hsted below must submit an EDS on its own behalf.

Name Titie Thomas F. WfilLs IV Trustee ^

2. Please provide the following information concerning each person or entity having a direct or indirect beneficial interest (including ownership) in excess of 7.5% ofthe Disclosing Party. Examples of such an interest include shares in a corporation, partnership interest in a partnership or joint venture.

Page 2 of 13

interest of a member or manager in a limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none, state "None." NOTE: Pursuant to Section 2-154-030 ofthe Municipal Code of Chicago ("Municipal Code"), the City may require any such additional information from any applicant which is reasonably intended to achieve full disclosure.


Carnlyn C. Wfills Ifi.Sni mils AVR, Flk Grnvfi VillaQR, H finfin? 100%

SECTION I I I - BUSINESS RELATIONSHIPS WITH CITY E L E C T E D OFFICIALS


[ ] Yes M No

If yes, please identify below the name(s) of such City elected official(s) and describe such relationship(s): ;


The Disclosing Party must disclose the name and business address of each subcontractor, attomey, lobbyist, accountant, consultant and any other person or entity whom the Disclosiag Party has retained or expects to retain in connection with the Matter, as well as the nature ofthe relationship, and the total amount of the fees paid or estimated to be paid. The Disclosing Party is not required to disclose employees who are paid solely through the Disclosing Party's regular payroll,

"Lobbyist" means any person or entity who undertakes to influence any legislative or administrative action on behalf of any person or entity other than: (1) a not-for-profit entity, on an unpaid basis, or (2) himself, "Lobbyist" also means any person or entity any part of whose duties as an employee of another includes undertaking to influence any legislative or administrative action.


Page 3 of 13

Name (indicate whether Business retained or anticipated Address to be retained) •




\X\ Check here i f the Disclosing Party has not retained, nor expects to retain, any such persons or entities.

SECTION V -- CERTIFICATIONS ,



Has any personjWho directly or indireptly owns 10% or more of the Disclosing Party been declared in arrearage on any child support obHgations by any Illinois court of competent jurisdiction?

[ ] Yes M No [ ] No person directly or indirectly owns 10% or more of the Disclosing Party.

I f "Yes," has the person entered into a court-approved agreement for payment of all support owed and is the person in compHance with that agreement?

[ ] Yes [ ] No

B. FURTHER 'CERTIFICATIONS

1. Pursuant to Municipal Code Chapter 1-23, Article I ("Article I")(which the Applicant should consult for defined terms (e.g., "doing business") and legal requirements), 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 AppHcant nor any controlling person is currently indicted or charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for, any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery, perjury, dishonesty or deceit against an officer or employee of the City or any sister agency; and (ii) the Applicant understands and acknowledges that compHance with Article I is a continuing requirement for doing business with the City. NOTE: If Article I appHes to the Applicant, the permanent compHance timeframe in Article I supersedes some five-year compliance timeframes in certifications 2 and 3 below.

Page 4 of 13

2. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities identified in Section I I .B. l . of this EDS: i i


b. have not, within a five-year period preceding the date of this EDS, been convicted of a criminal offense, adjudged guilty, or had a civiljudgment rendered against them in connection with: obtaining, attempting to obtain, or performing a public (federal, state or local) transaction or contract under a public transaction; a violation of federal or state antitrust stamtes; fraud; embezzlement; theft; forgery; bribery; falsification or destruction of records; making false statements; or receiving stolen property;

c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal, state or local) with committing any ofthe offenses set forth in clause B.2.b, of this Section V;





connection with the Matter, including but not limited to all persbns or legal entities disclosed under Section IV, "Disclosure of Subcontractors and Other Retained Parties"); • any "Affiliated Entity" (meaning a person or entity that, directiy or indirectly: controls the

Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under common control of another person or entity. Indicia of control include, without limitation; interlocking management or ownership; identity of interests among family members, shared facilities and equipment; common use of employees; or organization of a business entity following the ineligibility of a business entity to do business with federal or state or local government, including the City, using substantially the same management, ownership, or principals as the ineligible entity); with respect to Contractors, the term Affihated Entity means a person or entity that directly or indirectly controls the Contractor, is conttoUed by it, or, with the Contractor, is under common control of another person or entity; • any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any

other official, agent or employee ofthe Disclosing Party, any Contractor or any Affiliated Entity, acting pursuant to the direction or authorization of a responsible official ofthe Disclosing Party, any Contractor or any Affiliated Entity (collectively "Agents").

Page 5 of 13

Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing Party or any Contractor nor any Agents have, during the five years before the date this EDS is signed, or, with respect to a Contractor, an Affiliated, Entity, or an Affiliated Entity of a Contractor during the five years before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe, a pubhc officer or employee of the City, the State of Illinois, or any agency ofthe federal government or of any state or Ipcal government in the United States of America, in tiiat officer's or employee's official capacity;

b. agreed or colluded with other hidders or prospective bidders, or been a party to any such agreement, or been convicted or adjudged guilty of agreement or collusion among bidders or prospective bidders, in restraint of freedom o competition by agreement to bid a fixed price or otherwise; or




5. Neither the Disclosing Party nor any Affihated Entity is listed on any ofthe following lists maintained by the Office of Foreign Assets Control of the U.S. Department ofthe Treasury or the Bureau of Industry and Security ofthe U.S. Department of Commerce or their successors: the Specially Designated Nationals List, the Denied Persons List, the Unverified List, the Entity List and the Debarred List.



Page 6 of 13


8. To the best of the Disclosing Party's knowledge after reasonable inquiry, the foHowing is a complete list of all current employees ofthe Disclosing Party who were, at any time during the 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"). N/A

9. To the best of the Disclosing Party's knowledge after reasonable inquiry, the following is a complete list of all gifts that the Disclosing Party has given or caused to be given, at any time during the 12-month period preceding the execution date of this EDS, to an employee, or elected or appointed official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything made generally available to City employees or to the general public, or (ii) food or drink provided in the course of official City business and having a retail value of less than $20 per recipient (if none, indicate with "N/A" or "none"). As to any gift listed below, please also Hst the name of the City recipient. N/A



[ ] is ^ is not



"We are not and will not become a predatory lender as defined in Chapter 2-32 ofthe Municipal Code. We further pledge that none of our affihates is, and none of them will become, a predatory lender as defined in Chapter 2-32 of the Municipal Code, We understand that becoming a predatory lender or becoming an affiliate of a predatory lender may result in the loss ofthe privilege of doing business with the City."

I f the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in Section 2-32-455(b) ofthe Municipal Code) is a predatory lender within the meaning of Chapter 2-32 ofthe Municipal Code, explain here (attach additional pages if necessary): N/A

Page 7 of 13




1. In accordance with Section 2-156-110 of the jvlunicipal Code: Does any official or employee of the City have a financial interest in his or her own name or in the name of any other person or entity in the Matter?

[ ] Yes ^ ] No

NOTE: If you checked "Yes" to Item D.L, proceed to Items D.2. and D.3. I f you checked "No" to Item D. l . , proceed to Part E,

2. Unless sbld pursuant to a process of competitive bidding, or otherwise permitted, no City elected official or employee shall have a financial interest in his or her own name or in the name of any other person or entity in the purchase of any property that (i) belongs to the City, or (ii) is sold for taxes or assessments, or (iii) is sold by virtue of legal process at the suit of the City (collectively, "City Property Sale"). Compensation for property taken pursuant to the City's eminent domain power does not constitute a financial interest within the meaning of this Part D.


[ ] Yes [x] No :

3. If you checked "Yes" to Item D. l . , provide the names and business addresses ofthe City officials or employees having such interest and identify the nature of such interest:


4. The Disclosing Party further certifies that no prohibited financial interest in the Matter will be acquired by any City official or eniployee.



Page 8 of 13





NOTE; I f the Matter is federally funded, complete this Section V I . I f the Matter is not federally funded, proceed to Section VII . For purposes of this Section V I , tax credits allocated by the City and proceeds of debt obligations of the City are not federal fundings I


1. List below the names of all persons or entities registered under the federal Lobbying Disclosure Act of 1995 who have made lobbying contacts on behalf of the Disclosing Party with respect to the Matter; (Add sheets i f necessary);


2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay any person or entity listed in Paragraph A . l , above for his or her lobbying activities or to pay any person or entity to influence or attempt to influence an officer or employee of any agency, as defined by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee of a member of Congress, in connection with the award of any federally funded contract, making any federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew, amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

Page 9 of 13

3. The Disclosing Party wiH submit an updated certification at the end of each calendar quarter in which there occurs any event that materially affects the accuracy of the statements and information set forth in paragraphs A . l . and A.2. above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section 501(c)(4) of the Intemal Revenue Code of 1986; or (ii) it is an organization described in section 501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying Activities". ,

5. 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 jfederally funded, federal regulations require the Applicant and all proposed subcontractors to submit the following information with their bids or in writing at the outset of negotiations.

Is the Disclosing Party the AppHcant?

[ ] Yes [ ] No



[ ] Yes [ ] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract CompHance Programs, or the Equal Employment Opportunity Commission all reports due under the applicable filing requirements?

[ ] Yes [ ] No


[ ] Yes [ ] No

I f you checked "No" to question I . or 2. above, please provide an explanation:

Page 10 of 13



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 Govemmental Ethics and Campaign Financing Ordinances, Chapters 2-156 and 2-164 of the Municipal Code, impose certain duties and obligations on persons or entities seeking City contracts, work, business, or transactions. The fuH text of these ordinances and a tiaining program is available on Hne at www,citvofchicago.org/Ethics, and may also be obtained from the City's Board of Ethics, 740 N.


C. I f the City determines that any information provided in this EDS is false, incomplete or inaccurate, any contract or other agreement in connection with which it is submitted may be rescinded or be void or voidable, and the City may pursue any remedies under the contract or agreement (if not rescinded or void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter and/or declining to allow the Disclosing Party to participate in other transactions with the City. Remedies at law. for a false statement of material fact may include incarceration and an award to the City of treble damages.

D. It is the City's policy to make this document available to the pubHc on its Internet site and/or upon request. Some or all of the information provided on this EDS and any attachments to this EDS may be made available to the public on the Internet, in response to a Freedom of Information Act request, or otherwise. By completing and signing this EDS, the Disclosing Party waives and releases any possible rights or claims which it may have against the City in connection with the public release of information contained in this EDS and also authorizes the City to verify the accuracy of any information submitted in this EDS.

E. The information provided in this EDS must be kept current. In the event of changes, the Disclosing Party must supplement this EDS up to the time the City takes action on the Matter. I f the Matter is a contract being handled by the City's Department of Procurement Services, the Disclosing Party must update this EDS as the contract requires. NOTE; With respect to Matters subject to Article I of ' Chapter 1-23 ofthe Municipal Code (imposing PERMANENT INELIGIBILITY for certain specified offenses), the,information prpvided herein regarding eligibility must be kept current for a longer period, as required by Chapter 1-23 and Section 2-154-020 ofthe Municipal Code.


Page 11 of 13

F.l. The Disclosing Party is not delinquent in the payment of any tax administered by the Illinois Department of Revenue, nor are the Disclosing Party or its Affihated Entities dehnquent in paying any fine, fee, tax or other charge owed to the City, This includes, but is not limited to, ah water charges, sewer charges, license fees, parking tickets, property taxes or sales taxes.

F,2 If the Disclosing Party is the Applicant, the Disclosing Party and its Affihated Entities will not use, nor permit their subcontractors to use, any facility hsted by the U.S, E.P,A, on the federal Excluded Parties List System ("EPLS") maintained by the U, S, General Services Administration.

F,3 If the Disclosing Party is the Applicant, the Disclosing Party will obtain from any contractors/subcontractors hired or to be hired in connection with the Matter certifications equal in form and substance to those in F.l. and F.2. above and will not, without the prior written consent of the City, use any such contractor/subcontractor that does not provide such certifications or that the Disclosing Party has reason to beheve has not provided or camiot provide tmthful certifications,

NOTE; If the Disclosing Party cannot certify as to any pf the items in F.l., F.2, or F,3, above, an explanatory statement must be attached to this EDS,

CERTIFICATION

Under penaUy of perjury, the person signing below: (I) warrants that he/she is authorized to execute this EDS and Appendix A (if applicable) on behalf of the Disclosing Party, and (2) warrants that all certifications and statements contained in this EDS and Appendix A (if applicable) are true, accurate and complete as ofthe date furnished to the City,

' C. Wells Trust under agi-eenient dated 4/7/88 3f DiscAosing Party)

ngn here)

Thomas E. Wells IV (Print or type name of person signing)

Tmstee (Print or type title of person signing)

Signed and sworn to before me on (date) ^ ^ g feaigV ^ / y ^ / ^ . at County, Illinois (state).

Notary Public.

Commission expires:.

Page 12 of 13

OFFICIAL SEAL JAMES M BERTON

NOTARY PUBLIC • STATE OF ILLINOIS MY COMMISSION EXPIRES 10«5?/16


APPENDIX A



Under Municipal Code Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partaer thereof currently has a "famihal relationship" with any elected city official or department head. A "famihal relationship" exists if, as of the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Partner thereof is related to the mayor, any alderman, the city clerk, the city treasurer or any city department head as spouse or domestic partaer or as any ofthe following, whether by blood or adoption: parent, child, brother or sister, aunt or uncle, niece or nephew, grandparent, grandchild, father-in-law, mother-in-law, son-in-law, daughter-in-law, stepfather or stepmother, stepson or stepdaughter, stepbrother or stepsister or half-brother or half-sister,

"Applicable Party" means (1) all executive officers ofthe Disclosing Party Hsted in Section II.B,l.a., i f the Disclosing Party is a corporation; all partners ofthe Disclosing Party, i f the Disclosmg Party is a general partaership; all general partners and Hmited partners of the Disclosing Party, i f the Disclosing Party is a limited partaership; all managers, managing members and members ofthe Disclosing Party, if the Disclosing Party is a limited liabihty company; (2) all principal officers of the Disclosing Party; and (3) any person having more than a 7.5 percent ownership interest in the Disclosing Party. "Principal officers" means the president, chief operating officer, executive director, chief financial officer, tieasurer or secretary of a legal entity or any person exercising similar authority.

Does the Disclosing Party or any "Applicable Party" or any Spouse or Domestic Paitner thereof currently have a "familial relationship" with an elected city official or department head?

[ ] Yes M No

If yes, please identify below (I) the name and title of such person, (2) the name ofthe legal entity to which such person is connected; (3) the name and title of the elected city official or department head to whom such person has a familial relationship, and (4) the precise nature of such famiHal relationship.

Page 13 of 13


APPENDIX B


This Appendix is to be completed only by (a) the Applicant, and (b) any legal entity which has a direct ownership interest in the Applicant exceeding 7.5 percent (an "Owner"). It is not to be completed by any, legal entity which has only an indirect ownership interest in the Applicant.

1, Pursuant to Municipal Code Section 2-154-010, is tae Applicant or any Owner identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?

[ I ] Yes i [X] No i

2, I f the Applicant is a legal entity publicly traded on any exchange, is any officer or director of the Applicant identified as a building code scofflaw or problem landlord pursuant to Section 2-92-416 ofthe Municipal Code?

[ 3 Yes [ ] No [X] Not Applicable

If,yes to (1) or (2) above, please identify below the name of tlie person or legal entity identified as a building code scofflaw or problem landlord and the address of the building or buildings to which the pertinent code violations apply.

FILLING OUT THIS APPENDIX B CONSTITUTES ACKNOWLEDGMENT AND AGREEMENT THAT THIS APPENDIX B IS INCORPORATED BY REFERENCE INTO, AND MADE A PART OF, THE ASSOCIATED EDS, AND THAT THE REPkESENTATIONS MADE IN THIS APPENDIX B ARE SUBJECT TO THE C E : R T I F I C A T I 0 N MADE UNDER PENALTY OF PERJURY ON PAGE 12 OF THE ASSOCIATED EDS.

Documents

Jahn Design Proposal