City of Chicago

02019-271
Office of the City Clerk

Qocument Tracking Sheet

Meeting Date: 1/23/2019

Sponsor(s): Misc. Transmittal
Type: Ordinance
Title: Zoning Reclassificatk)n;Map No. 7-J at 2922-2924 N Central
Park Ave and 3609 Vy Ogkdale Aye - App No. 19920
Committee(s) Assignment: Committee on Zoning, Landmarks and Buildjng Standards
 ORDINANCE

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

SECTION 1. Title 17 of the Municipal Code of Chicago, the Chicago Zoning Ordinance, is
hereby amended by changing all of the B3-2 Community Shopping District symbols and
indications as shown on Map No. 7-J in the area bounded by

West Oakdale Avenue; North Central Park Avenue; a line 58.45 feet south of and parallel
to West Oakdale Avenue; and the alley next west of and parallel to North Central Park
Avenue

to those of a CI-3 Neighborhood Commercial District.

SECTION 2. This ordinance shall be in force and effect from and after its passage and due
publication.

Common Address of Property; 2922-24 N. Central Park Avenue / 3609 W. Oakdale Avenue. Chicago, Illinois 60618
 PLAT OF SURVEY
DESCRIBED AS:
LOTS 1 AND 2 I N T H E SUnDIVISION OF PARTS OF LOTS 1 AND : I N J. B. DAWSON'S
SUBDIVISION OF L O T 9 I N D A V L I N , K E L L V AND C A R R O L L ' S SUDDrVISION OF T H E
NORTHWEST 1/4 OF SECTION 16, TOWNSHIP 40 NORTH, RANGE 1 J, EAST OF T H E
THIRD PRINCIPAL M E R I D I A N , ACCORDING TO T H E PLAT RECORDED JUNE 6, 1909, AS
DOCUMENT4386630, IN COOK COUNTY, ILLINOIS.

W. OAKDALE AVE.

.,\V\«>1'"I"//,/;; .

LBGBNJ)
• CHAIN IMKFEUCE # . O V ' 35-325B --.^l
• WOOD FENCE
• IRON FENCE * < ' •• REGISTERED
• CONCRETE PAVEMENT I LAND :.
E FK. P. - ENCLOSED FRAME PORCH
O. FR. P. - OPEN FRAME PORCH I 1 SURVEYOR :
- SIDE BOUNDARy LINE I STATE OF /
• EASEMENT UNE
• BLDC. SETBACK LINE % \, ILLINOIS
• CENTER UNE

ALL DIMENSIONS ARE SHOWN IN FEF.T STATE OF ILLINOIS SIGNATURE D.\TE:

AND DECIMAL PARTS THEREOF. •^^f{'f.^..tf..^..
COUNTY OF COOK ss *'///;/iiiiii\i'.*^*
SCALE: ./-r.fT/fsrr.
- n M x v ^ e B> D J t -—•LANDRZEJMURZANSKl, AN ILLINOIS REGISTERED LAND SUnVEVOR, DO
O R D E R E D : Ttfffm'f.S.f<.: f ^ ^ f f y ^ ^ r T T / IIERBY CERTIFY THAT I HAVE SURVEYED THE ABOVE DESCRIBED ANDRZEJ MURZANSKI
PROPERTY AND THAT PLAT HEREON DRAWN IS A CORRECT LAND SUnVEYORS, INC
JOB NO : REPRESENTATION OF SAID SJIRVEY^^p PROFESSIONAL DESIGN FIRM
FIELDWORK NO. 184^00474!
COMrLCTION
DATE: ANDRZEJ M i n C U N S K I PLS. NO. 35-3258 EXPIRES 11/30/2020
240 COUNTRY LANE
THIS PROFESSIONAL SERVICE CONFORMS TO THE CURRENT ILLINOIS
MUMCirALITY: MINIMUM STANDARDS FOR A BOUNDARY SURVEY. GLENVIEW, I L 60025
PHONE: 847-486-8731
ANY DISCREPANCY IN MEASURMENT SHOULD Bli PROMPTLY REPORTED TO FAX: 847-486-8732
THE SURVEYOR FOR EXPLANATION OR CORRECflOR
THE LEGAL DESCRIPTION NOTED ON [email protected]
THIS PLAT IS A COPY OF THE ORDERS FOR EASEMENTS, BUILDING LINES AND OTHER RESTRICTIONS NOT SHOWN ON
AND FOR ACCURACY MUST BE THIS PLAT REFER TO YOUR ABSTRACT, DEED, TITLE POLICY AND LOCAL
BUILDING REGULATIONS.
COMPARED WITH THE DEED.
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 THOMAS R. RAINES
A X X O R > < E Y A T LAAV, L L C
2 0 iV. W A C K E R D R I V E ' STITITE 5 5 6
CHICAC40. I L L I N O I S 60606
(312) 7 5 0 - 1 1 6 6 • (312) 7 5 0 - 1 1 6 4

"WRITTEN NOTICE"
FORM OF AFFIDAVIT
(SECTION 17-13-0107)
January 15,2019

Honorable Daniel S. Solis

Chairman, Committee on Zoning
121 North LaSalle Street
Room 304, City Hall
Chicago, IL 60602

The undersigned, Thomas Raines, being first duly sworn on oath deposes and states the
following:

The undersign certifies that he has complied with the requirements of Section 17-13-0107
of the Chicago Zoning Ordinance, by sending written notice to such property owners who
appear to be the owners of the property within the subject area not solely owned by the
applicant, and to the owners of all property within 250 feet in each direction of the lot
lines of the subject property, exclusive of public roads, streets, alleys, and other public
ways, or a total distance limited to 400 feet. Said "written notice" was sent by First Class
U.S. Mail, no more than 30 days before filing the application.

The undersigned certifies that the notice contained the address of the property sought to
be rezoned; a statement of the intended use of the property; the name and address of the
applicant; the name and address of the owner; and a statement that the applicant intends
to file the application for a change in zoning on approximately January 16, 2019.

The undersigned certifies that the applicant has made a bona fide effort to determine the
addresses of the parties to be nofified under Section 17-13-0107 of the Chicago Zoning
Ordinance, and that the accompanying list of names and addresses of surrounding
property owners within 250 feet of the subject site is a complete list containing the names
and addresses of the people required to be served.
Very tyuly yours.

Thomas R. Raines
OFFICIAL SEAL bscribed and sw,om to before me this
PAULA BOEHM ()o^^iAJx^vy , 2019.
Notary Public - State ot Illinois
My Commission Expires Apr 8, 2019
w <d» w «
Notary Public
 T H O M A S R. RAIISTES
AXTORiSEY A T L A W ,L L C
2 0 ?sr. W A C I v E R O R I V E • S t J I X E 55Ci
CHICAOO. ILLINOIS 60606
(312) 7 5 0 - 1 1 6 6 • (312) 7 5 0 - 1 1 0 4

January 15,2018

Dear Property Owner:

In accordance with Section 17-13-0107 of the Chicago Zoning Ordinance, please

be informed that on or about January 16,2018, the undersigned will file an application
for a change in zoning from a B3-2 Community Shopping District to a Cl-3
Neighborhood Commercial District on behalf of 2922-24 North Central Park, LLC (the
"Applicant") for the property located at 2922-24 N. Central Park Ave. / 3609 W. Oakdale
Ave., Chicago, IL 60618 (the "Subject Property").

The Applicant is seeking a zoning amendment for the Subject Property to erect a 1 story
addition on the south elevation (10'-2" in height, 930 sq. feet in area), with alterations to
the existing 1*' floor space to include the de-conversion of the 1^' floor rear dwelling unit
and expansion of the existing tavern into the entire 1 ^' floor space, and to expand the
tavern into an outdoor patio space on the ground level in the adjacent lot to the south
(1,821 sq. feet in area). The building located at 2922-24 N. Central Park Ave. / 3609 W.
Oakdale Ave., Chicago, IL 60618 is 7,374 square feet, consisting of 3 stories & a
basement space. The entire ground floor will be utilized as a tavern with four dwelling
units total on the second & third floors. There are no changes proposed to the dwelling
units on the second & third floors.

The owners of the Subject Property are Zdzislaw & Stanislawa Sitarz and they are
located at 3609 W. Oakdale Ave., Chicago, IL 60618. The contact person for this
application is attorney Thomas R. Raines who may be reached at 312-750-1166.

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

Very touly yours.

lotnas R. Raines
January 15, 2019

Honorable Daniel S. Solis

Chairman, Committee on Zoning

121 North LaSalle Street

Room 304, City Hall

Chicago, IL 60602

Re: Zoning Amendment for 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave.

Dear Chairman Solis,

The undersigned certifies that he is the owner of the above referenced property. Please be
advised that, 2922-24 North Central Park, LLC, an Illinois Limited Liability Corporation, is hereby
authorized to file and process an application for a Zoning Amendment in order to change the
zoning from a B3-2 Community Shopping District to a Cl-3 Neighborhood Commercial District.

Sincerely,

-Zdzislaw Sitarz

Owner of 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave.

-Stanislawa Sitarz

Owner of 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave.

 CITY OF CHICAGO

APPLICATION FOR AN AMENDMENT TO

THE CHICAGO ZONING ORDINANCE

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

2922-24 N. Central Park Avenue / 3609 W. Oakdale Avenue

2. Ward Number that property is located in: 30th

3 APPLICANT 2922-24 N. CENTRAL PARK, LLC

ADDRESS 1535 N. ELSTON AVE. Q T Y CHICAGO

STATE "- ZIP CODE 60642 PHONE 773-227-7224

EMAIL [email protected] CONTACT PERSON DAVID HALPERN

Is the applicant the owner of the property? YES NO ^

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.
r^M/xTCD ZDZISLAW & STANISLAWA SITARZ
OWNER
ADDRESS 3609 W. OAKDALE AVENUE ^ y ^ ^ CHICAGO

STATE_JL ZIP CODE ^0618 PHONE.

EMAIL CONTACT PERSON ZDZISLAW SITARZ

5. If the Applicant/Owner of the property has obtained a lawyer as their representative for the
rezoning, please provide the following information:

ATTORNEY THOMAS R. RAINES, ATTORNEY AT LAW, LLC

ADDRESS 20 N. WACKER DRIVE

CITY CHICAGO STATE IL ZIP CODE 60606

PHONE 312-750-1166 p^x 312-750-1164 EMAIL [email protected]

 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.
DAVID HALPERN
BENJAMIN KLOPR

ROBERT DECK

SCOTT SPIDALE
JOHN C. WALL

PETER T. WALL

7. On what date did the owner acquire legal title to the subject property? SEPTEMBER 1, 1979

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

9. Present Zoning District ^3-2 Proposed Zoning District "^^'3

10. Lot size in square feet (or dimensions) 6,418.09 SQUARE FEET

11. Current Use of the property TAVERN & 5 DWELLING UNITS

„ . , ERECT 1 STORY ADDITION 10'-2" IN HEIGHTS 930 SQ.FT. IN AREA ON SOUTH ELEVATION,
12. Reason for rezonmg the property
ALTERATIONS OF EXISTING 1ST FLOOR TAVERN TO DE-CONVERT 1ST FL REAR DWELLING UNIT & EXPAND TAVERN TO ENTIRE 1ST FL

SPACE & EXPANSION OF 1ST FL TAVERN INTO OUTDOOR PATIO SPACE AT GROUND LEVEL, 1,821 SQ. FT. IN AREA.

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)
PROPOSED USE OF THE PROPERTY WILL BE A 1ST FLOOR TAVERN, APPROX. 3,162 SF, TOTAL WITH
NEW ADDITION AND AN EXPANSION OF THE TAVERN TO AN OUTDOOR PATIO AT GROUND LEVEL,
APPROX. 1,821 SF, WITH NO CHANGES TO THE EXISTING 4 DWELLING UNITS ON THE SECOND &

THIRD FLOORS. FOUR (4) ON-SITE PARKING SPACES WILL BE PROVIDED AT REAR OFF OF ALLEY.
14. The Affordable Requrements Ordinance (ARO) requires on-site affordable housing units and/or
afinancialcontribution for residential housing projects with ten or more units that receive a zoning
change which, among other triggers, increases the allowable floor area, or, for existing Planned
Developments, increases the number of units (see attached fact sheet or visit
www.cityofchicago.org/ARO for more information). Is this project subject to the ARO?

YES NO X
COUNTY OF COOK
STATE OF ILLINOIS

DAVID HALPERN , being first duly sworn on oath, states that all of the above
statements and the statements contained in the documents submitted herewith are true and correct.

Signature of Appfipant

Subscribed and Sworn to before me this .^v,

\kJL-day of ^0.^^^o.^y , 20 \0\ . | OFFICIAL SEAL
PAULA BOEHM

Notary Public
L Notary Public - State of Illinois
My Commission Expires Apr 8, 2019

For Office Use Only

Date of Introduction:

File Number:

Ward:
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

2922-24 N. Central Park, LLC

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [•) the Applicant
OR
2. Q a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
3. Q a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 773-227-7224 p^x: 773-489-2580 Email: [email protected]

D. Name of contact person: David Halpern

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change tiie zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C l - 3 .

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Page 1 of 15
SECTION II -- DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

• Person [•] Limited liability company
Publicly registered business corporation | ^ Limited liability partnership
Privately held business corporation Q Joint venture
Sole proprietorship Not-for-profit corporation
General partnership (Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership Q Yes Q No
Trust 1 ^ Other (please specify)

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

Illinois

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

I I Yes cn 0 Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Ctiicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

[See Section 11(B)(2) Schedule attached hereto for additional responsive information]

SECTION III - INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY E L E C T E D

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? CH 0 No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? | ^ Yes [•] No

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

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

SECTION IV " DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

• Yes [•jNo Q N O person directly or indirectly owns 10% or more of the Disclosing Party.

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

[ ] Yes [ ] NO

B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or contract under a
public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery;
bribery; falsification or destruction of records; making false statements; or receiving stolen property;

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 subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

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

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee 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 subparagraph (a) or (b) above that is a matter of
record, but have not been prosecuted for such conduct; or

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.

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

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

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

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

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

13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

[~| is [•] is not

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

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 MCC Chapter 2-32. We further
pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in
MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a
predatory lender may result in the loss of the privilege of doing business with the City."

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have a financial interest in his or
her own name or in the name of any other person or entity in the Matter?

Q Yes [•] No

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

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

Does the Matter involve a City Property Sale?

• Yes 0No

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

JZl1. 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.
112. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI " CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
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.

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," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

0 Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes g 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?
1 I Yes • No [^Reports not required

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:
N/A

Ver.2018-1 Page 10 of 15
SECTION VII " FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

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

B. The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City contracts, work, business, or transactions. The full text
of this ordinance and a training program is available on line at www.cityofchicago.org/Ethics, and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

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 City transactions. 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 in, and appended to, this EDS may be made publicly
available on the Internet, in response to a Freedom of Information Act request, or otherwise. By
completing and signing this EDS, the Disclosing Party waives and releases any possible rights or
claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.

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 MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

2922-24 North Central Park, LLC

(Print or type exact legal name of Disclosing Party)

By: A<^lHf*^
(Sign here)
David Halpern
(Print or type name of person signing)
Manager
(Print or type title of person signing)

Signed and sworn to before me on (date) Decennber 7, 2018

at Cook County, '"'"O'S (state).

Notary Public

Commission expires:

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS

AND DEPARTMENT HEADS

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

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

"Applicable Party" means (1) all executive officers 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% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

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

• Yes 0 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.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes n N° 0 The Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

[•I N/A - 1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT -
2922-24 NORTH CENTRAL PARK. L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners of the Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name of the Disclosing Party submitting this EDS. Include d^/a/ if applicable:
Robert P. Deck

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2. [•] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North Central Park, LLC
OR
3. • a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 513-520-7246 pax: 773-489-2580 Email: [email protected]

D. Name of contact person: Robert P. Deck

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Page 1 of 15
SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

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

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?

I I Yes • No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue. Chicago, IL 60642 12.5%

[See Section 11(B)(2) Schedule attached hereto for additional responsive infomiation]

SECTION III ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [•] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [•] No

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

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

SECTION rV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

• Yes l^jNo Q N O person directly or indirectly owns 10% or more of the Disclosing Party.

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

• Yes QNO

B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of anyfine,fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or contract under a
public transaction; a violation of federal or state antitrust statutes;fi-aud;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 subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

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

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee 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 subparagraph (a) or (b) above that is a matter of
record, but have not been prosecuted for such conduct; or

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

6. Neither the Disclosing Party, nor any Affiliated Entity or Contractor, or any of their employees,
officials, agents or partners, is barredfi"omcontracting 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.

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.

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

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

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

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

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

13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
• is [•I is not

a "fmancial institution" as defined in MCC Section 2-32-455(b).

2. If the Disclosing Party IS afinancialinstitution, then the Disclosing Party pledges:

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

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defmed in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have a fmancial interest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes [•] No

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

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected
official or employee shall have afinancialinterest 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 afinancialinterest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

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

Name Business Address Nature of Financial Interest

4. The Disclosing Partyfiirthercertifies that no prohibited fmancial interest in the Matter will be
acquired by any City official or employee.

Ver.2018-1 Page 8 of 15
 E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

Ell.
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.
I 12 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 profitsfromslavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes fiill disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: If the Matter is federally funded, complete this Section VI. If the Matter is not
federally funded, proceed to Section 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, as amended, who have made lobbying contacts on behalf of the Disclosing
Party with respect to the Matter: (Add sheets if necessary):
N/A

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

2. The Disclosing Party has not spent and will not expend any federally appropriatedfimdsto pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
 of a member of Congress, in cormection 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.

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," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.

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

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[•I Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have onfileaffirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes (•] No

2. Have youfiledwith 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?
I I Yes • No PI Reports not required

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:
N/A

Ver.2018-1 Page 10 of 15
SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

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

B. The City's Govermnental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City contracts, work, business, or transactions. The full text
of this ordinance and attainingprogram is available on line at wvyw.cityofchicago.org/Ethics. and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

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 City transactions. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of tteble
damages.

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

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 MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
 CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate
and complete as of the datefiimishedto the City.

Robert P. Deck
(Print or type exact legal name of Disclosing Party)

By:
>ign here)
Robert P. Deck
(Print or type name of person signing)
Individual
(Print or type title of person signing)

Signed and sworn to before me on (date) December 7. 2018

Cook CQuntyJIinO'S (state).
OFFICIALSEAL
PAULA BOEHM
Notary Publi Notary Public - State of Illinois
My Commission Expires Apr 8, 2019

Commission expires: (}^V\ I ^,^01^

Ver.2018-I Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial
relationship" with any elected city official or department head. A "familial relationship" exists if, as 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% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
fmancial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

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

• Yes gNo
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.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity pubhclyttadedon any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes n 0 Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (vmw.amlegal.com).
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Apphcant is in compliance with MCC Section 2-92-3 85(b)(1) and (2), which prohibit: (i) screening
job apphcants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

[•] N/A - 1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.

This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(1).

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
2922-24 NORTH CENTRAL PARK. L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners of the Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2. [•] a legal entity currently holding, or anticipated to hold within six months after City action on
the conttact, transaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North central Park, LLC
OR
3. • a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 773-486-2570 pax: 773-489-2580 Email: [email protected]

D. Name of contact person: Peter T. Wall

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or departinent is requesting this EDS? Planning & Development

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

Specification # and Conttact #

Ver.2018-1 Paget of 15
 SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

2. For legal entities, the state (or foreign countty) of incorporation or organization, if applicable:
N/A

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?

I I Yes •No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
 i
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago. IL 60642 12.5%

[See Section il(B)(2) Schedule attached hereto for additional responsive information]

SECTION III ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [•] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [•] No

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

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subconfractor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

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

• Yes •No
B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a conttact being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of anyfine,fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018.1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or conttact 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 subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public ttansactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• the Disclosing Party;
• any "Conttactor" (meaning any contractor or subconfractor 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 Subconttactors and Other Retained Parties");
• any "Affiliated Entity" (meaning a person or entity that, directly or indirectly: conttols the
Disclosing Party, is confrolled by the Disclosing Party, or is, with the Disclosing Party, under
common confrol of another person or entity). Indicia of conttol 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 Confractors, the term Affiliated Entity means a person or entity
that directly or indirectly conttols the Conttactor, is controlled by it, or, with the Conttactor, is
under common control of another person or entity;
• any responsible official of the Disclosing Party, any Conttactor or any Affiliated Entity or any
other official, agent or employee of the Disclosing Party, any Conttactor or any Affiliated Entity,
acting pursuant to the direction or authorization of a responsible official of the Disclosing Party,
any Conttactor or any Affiliated Entity (collectively "Agents").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affihated Entity of either the Disclosing
Party or any Conttactor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Conttactor, an Affiliated Entity, or an Affiliated Entity of a Conttactor during the 5 years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee 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 resfraint offi-eedomof competition by agreement to bid afixedprice or otherwise; or

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

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

6. Neither the Disclosing Party, nor any Affiliated Entity or Conttactor, or any of their employees,
officials, agents or partners, is barredfromconttacting 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.

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasvuy, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) NeithertiieApplicant nor any "confrolling person" [see MCC
Chapter 1-23, Article I for applicability and defined terras] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliancetimeframesin this Section V.

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

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

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

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

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

13. 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 anytimeduring
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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
• is !•] is not

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

2. If the Disclosing Party IS afinancialinstitution, then the Disclosing Party pledges:

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

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terras defmed in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have afinancialinterest in his or
her own name or in the name of any other person or entity in the Matter?

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

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

Does the Matter involve a City Property Sale?

• Yes [TlNo

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
 E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investraents 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.

EZI2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: I f the Matter is federally funded, complete this Section 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 . List below the names of all persons or entities registered under the federal Lobbying
Disclosure Act of 1995, as amended, who have made lobbying contacts on behalf of the Disclosing
Party with respect to the Matter: (Add sheets if necessary):
N/A

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
 of a member of Congress, in connection with the award of any federally funded conttact, making any
federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew,
amend, or modify any federallyftmdedconfract, grant, loan, or cooperative agreement.

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," as that terra is defined in the Lobbying Disclosure Act of 1995, as amended.

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) abovefromall subconttactors before it awards
any subconfract and the Disclosing Party must maintain all such subconttactors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

0 Yes • No
If "Yes," answer the three questions below:

1. Have you developed and do you have onfileaffirmative action programs pursuant to appUcable
federal regulations? (See 41 CFR Part 60-2.)
• Yes {•] No

2. Have youfiledwith the Joint Reporting Committee, the Director of the Office of Federal Confract
Compliance Programs, or the Equal Employment Opportunity Comraission all reports due under the
applicablefilingrequirements?
1 I Yes • No [^Reports not required

3. Have you participated in any previous contracts or subconttacts subject to the

equal opportunity clause?
• Yes ^ No

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

Ver.2018-1 Page 10 of 15
 SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any
conttact 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 Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City confracts, work, business, orfransactions.The full text
of this ordinance and afrainingprogram is available on line at wvyw.cityofchicago.org/Ethics. and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate,
any confract or other agreement in connection with which it is submitted may be rescinded or be void
or voidable, and the City may pursue any remedies under the confract 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 Cityfransactions.Remedies at
law for a false statement of material fact may include incarceration and an award to the City of freble
daraages.

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 in, and appended to, this EDS may be made publicly
available 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 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 thetimethe City takes action on the Matter. If the Matter is a
conttact being handled by the City's Department of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

Peter T. Wall
(Print or type exact legal name of Disclosing Party)

By: ^T.UM
(Sign here)
Peter T. Wall
(Print or type name of person signing)
Individual
(Prmt or type title of person signing)

Signed and sworn to before me on (date) December 7, 2018

at Cook ^ ^ County, """O'S (state).

OFFICIALSEAL
NotanTPublic '— 4 PAULABOEHM
Notary Public - State ot Illinois
My Commission Expires Apr 8, 2019

Commission expires:

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial
relationship" with any elected city official or department head. A "familial relationship" exists if, as of
the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic
Partner thereof is related to the mayor, any alderman, the city clerk, the citytteasureror 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.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; allraanagers,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% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
fmancial officer,tteasureror secretary of a legal entity or any person exercising similar authority.

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

• Yes [•JNo
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.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity pubhclyttadedon any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

{ I Yes n 0 Applicant is not publicly traded on any exchange.

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

Ver.2018.1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "conttactor" as
defined in MCC Section 2-92-385. That section, which should be consulted (vyww.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a hcense, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Apphcant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes
• No
[•j N/A - 1 am not an Applicant that is a "confractor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
2922-24 NORTH CENTRAL PARK, L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners of the Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

John C. Wall

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2 . 0 a legal entity currently holding, or anticipated to hold within six months after City action on
the conttact,fransactionor other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North Central Park, LLC
OR
3. • a legal entity with a direct or indirect right of confrol of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of confrol:

B. Business address ofthe Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 773-671-8842 pax: 773-489-2580 Email: [email protected]

D. Name of contact person: John C. Wall

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to ctiange the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Paget of 15
SECTION II ~ DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

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

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?

I I Yes •No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpem Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

[See Section 11(B)(2) Schedule attached hereto for additional responsive information]

SECTION III ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes {•] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes {•] No

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

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

SECTION IV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attomey,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attomey; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V - CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under MCC Section 2-92-415, substantial owners of business entities that conttact with the City must
remain in compliance with their child support obligations throughout the conttact'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 l^jNo Q N O person directiy or indirectly owns 10% or more of the Disclosing Party.

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

• Yes • No

B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or contract under a
public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery;
bribery; falsification or destruction of records; making false statements; or receiving stolen property;

c. are not presently indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with comraitting any of the offenses set forth in subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• 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, directiy or indirectiy: controls the
Disclosing Party, is controlled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity). Indicia of conttol 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 conttols the Contractor, is controlled by it, or, with the Confractor, is
under common confrol 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").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee 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 afixedprice or otherwise; or

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

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Conttacts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "controlling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1 -23, Article 1 applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliancetimeframesin this Section V.

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

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

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

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

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

13. 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 anytimeduring
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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

• is [•] is not

a "financial institution" as defmed in MCC Section 2-32-455(b).

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 MCC Chapter 2-32. We further
pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in
MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a
predatory lender may result in the loss of the privilege of doing business with the City."

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable toraakethis pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have a financial interest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes 0 No
NOTE: If you checked "Yes" to Item D(l), proceed to Items D(2) and D(3). If you checked "No"
to Item D(l), skip Items D(2) and D(3) and proceed to Part E.

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

Does the Matter involve a City Property Sale?

• Yes gNo

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

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
frora slavery or slaveholder insurance policies during the slavery era (including insurance policies
issued to slaveholders that provided coverage for daraage to or injury or death of their slaves), and
the Disclosing Party has found no such records.

EZI2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investments or profits from slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the names of any and all slaves or slaveholders described in those records:

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

NOTE: I f the Matter is federally funded, coraplete 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, as amended, who have made lobbying contacts on behalf of the Disclosing
Party with respect to the Matter: (Add sheets if necessary):
N/A

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or atterapt to influence an officer or eraployee of any agency, as defmed
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a meraber of Congress, in cormection with the award of any federally funded contract,raakingany
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.

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 inforraation set
forth in paragraphs A(l) and A(2) above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities," as that terra is defined in the Lobbying Disclosure Act of 1995, as amended.

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 subconttactors' certifications for the
duration of the Matter andraustmake 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?

0 Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes [•] No

2. Have youfiledwith the Joint Reporting Coramittee, the Director of the Office of Federal Contract
Compliance Programs, or the Equal Employment Opportunity Comraission all reports due under the
applicablefilingrequireraents?
1 I Yes • No [^Reports not required

3. Have you participated in any previous contracts or subconttacts subject to the

equal opportunity clause?
• Yes 0 No

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

Ver.2018-1 Page 10 of 15
SECTION VII ~ FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgraents 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 induceraents to the City's execution
of any conttact 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 Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City contracts, work, business, orfransactions.The full text
of this ordinance and a training program is available on line at www.cityofchicago.org/Ethics. and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

C. If the City determines that any inforraation provided in this EDS is false, incoraplete 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 conttact 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 Cityttansactions.Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.

D. It is the City's policy to make this document available to the public on its Intemet site and/or upon
request. Some or all ofthe information provided in, and appended to, this EDS may beraadepublicly
available on the Internet, in response to a Freedom of Inforraation Act request, or otherwise. By
corapleting 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 inforraation
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 raust
update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter
1-23, Article I (iraposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION
Under penalty of perjury, the person signing below: (1) warrants that he/she is authorized to execute
this EDS, and all applicable Appendices, on behalf of the Disclosing Party, and (2) warrants that all
certifications and statements contained in this EDS, and all applicable Appendices, are true, accurate
and complete as of the date furnished to the City.

John C. Wall
(Print or type exact legal name of Disclosing Party)

Bv: j k v ^ ^
(j(Sign here)
John C. Wall
(Print or type name of person signing)
Individual
(Print or type title of person signing)

Signed and swom to before me on (date) December 7, 2018

at C o o k _ _ ^ c o u n t y , '"'"O'S (state).

OFFICIALSEAL
Notary Public i PAULA BOEHM
Notary Public - State of Illinois
My Commission Expires Apr 8, 2019

Coraraission expires: Qpkl) ^jU^i^

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Partyraustdisclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Doraestic Partner thereof currently has a "farailial
relationship" with any elected city official or department head. A "farailial 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 alderraan, the city clerk, the citytteasureror any city
departraent 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,raanagingraerabersandraembersof the
Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers of the
Disclosing Party; and (3) any person havingraorethan a 7.5% ownership interest in the Disclosing
Party. "Principal officers"raeansthe president, chief operating officer, executive director, chief
financial officer, treasurer or secretary of a legal entity or any person exercising sirailar authority.

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

• Yes l^jNo
If yes, please identify below (1) the name and title of such person, (2) the narae of the legal entity to
which such person is connected; (3) the narae and title ofthe elected city official or departraent head to
whora such person has a familial relationship, and (4) the precise nature of such familial relationship.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes n 0 Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is corapleting this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former eraployers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes
• No
j ^ ] N/A - 1 ara not an Applicant that is a "conttactor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT -
2922-24 NORTH CENTRAL PARK. L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners of the Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2., [ / ] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract,fransactionor other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North Central Park, LLC
OR
3. • a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of control:

B. Business address ofthe Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 312-401-7743 pax: Email: [email protected]

D. Name of contact person: Scott W. Spidale

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

F. Brief description ofthe Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to ctiange ttie zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Conttact #

Ver.2018-1 Page 1 of 15
SECTION H ~ DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

Person I I Limited liability company
Publicly registered business corporation I I Limited liability partnership
Privately held business corporation I I Joint venture
Sole proprietorship I I Not-for-profit corporation
General partnership (Is the not-for-profit corporation also a 501(c)(3))?
Limited partnership • Yes QNo
Trust I I Other (please specify)

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

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?

I I Yes • No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Ctiicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

[See Section 11(B)(2) Sctiedule attactied tiereto for additional responsive information]

SECTION HI ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [/] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [/| No

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

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subconttactor, attomey,
lobbyist (as defmed in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

• Yes |7|No [ ] N o person directly or indirectly owns 10% or more of the Disclosing Party.

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

• Yes • No
B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local)ttansactionor conttact 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 subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions conceming
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• 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: conttols 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 conttols 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 of the Disclosing Party,
any Conttactor or any Affiliated Entity (collectively "Agents").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Conttactor, an Affiliated Entity, or an Affiliated Entity of a Conttactor during the 5 years
before the date of such Contractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

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

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

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

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Miniraum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. . [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "conttolling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.

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

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

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

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

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

13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name ofthe City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
[~| is [/] is not

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

2. If the Disclosing Party IS afinancialinstitution, then the Disclosing Party pledges:

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

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have afinancialinterest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes |7] No

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

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

Does the Matter involve a City Property Sale?

• Yes [7] No

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDEMG LOBBYING

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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a member of Congress, in connection with the award of any federally funded conttact, 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.

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

4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.

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 subconttactors before it awards
any subconttact and the Disclosing Party must maintain all such subconttactors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[7] Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes [7] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Conttact
Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the
applicable filing requirements?
I I Yes • No [7j Reports not required

3. Have you participated in any previous contracts or subcontracts subject to the

equal opportunity clause?
• Yes [7] No

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

Ver.2018-1 Page 10 of 15
SECTION V n ~ FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

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

B. The City's Governmental Ethics Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City contracts, work, business, or transactions. The full text
of this ordinance and a training program is available on line at 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 this ordinance. .

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 City transactions. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.

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

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 MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

Scott W. Spidale
(Print or ^fy^Q exact legal jaame of Disclosing Party)

By: (XVvi^L
(Sign here)
Scott W. Spidale
(Print or type name of person signing)
Individual
(Print or type title of person signing)

Signed and swom to before me on (date) December 7, 2018

at
Cook County, '"'"Q'S (state).

Notary PuWic OFFICIAL SEAL

PAULA BOEHI>/l
Notary public-State o t l »
My commission Expires Apr 8, 2019
Commission expires: [ l .^'l^l ^[X^^^

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

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

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

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

• Yes 171No
If yes, please identify below (1) the name and title of such person, (2) the name ofthe legal entity to
which such person is connected; (3) the name and title ofthe elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 17] No
2. If the Applicant is a legal entity publiclyttadedon any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes • No [7] The Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (vvfww.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

[/] N/A - 1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.

This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(1).

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
2922-24 NORTH CENTRAL PARK, L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners ofthe Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I -- GENERAL INFORMATION

A. Legal name ofthe Disclosing Party submitting this EDS. Include d^/a/ if applicable:
David Halpern

Check ONE ofthe following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2. [7] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract,ttansactionor other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North Central Park, LLC
OR
3. • a legal entity with a direct or indirect right of conttol of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of conttol:

B. Business address of the Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone: 773-227-7224 p^x: 773-489-2580 Email: [email protected]

D. Name of contact person: David Halpern

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

F. Brief description ofthe Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Paget of 15
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

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

N/A

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?

I I Yes •No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its ovm behalf

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

[See Section 11(B)(2) Schedule attached hereto for additional responsive information]

SECTION III ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [/] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [/] No

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

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

SECTION TV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

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

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subconttactor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLLANCE

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

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

I I Yes [/] 0 person directly or indirectly owns 10% or more of the Disclosing Party.

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

• Yes •No
B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a conttact in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in cormection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or conttact under a
publicttansaction;a violation of federal or state antitmst statutes;fi^aud;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 subparagraph (b) above;

d. have not, durmg the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions conceming
environmental violations, instituted by the City or by the federal govemment, any state, or any other
unit of local govemment.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• 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: conttols the
Disclosing Party, is conttoUed by the Disclosing Party, or is, with the Disclosing Party, under
common conttol 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 govemment,
including the City, using substantially the same management, ownership, or principals as the
ineligible entity. With respect to Conttactors, the term Affiliated Entity means a person or entity
that directly or indirectly conttols 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 Conttactor 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").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Conttactor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Conttactor, an Affiliated Entity, or an Affiliated Entity of a Conttactor during the 5 years
before the date of such Conttactor's or Affiliated Entity's contract or engagement in cormection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee ofthe City, the State of Illinois, or any agency of the federal govemment
or of any state or local govemment 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 resttaint of freedom of competition by agreement to bid afixedprice or otherwise; or

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

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Conttacts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither tiie Applicant nor any "conttolling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] ofthe Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee 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 MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliancetimeframesin this Section V.

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

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

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

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

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

13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name ofthe City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL DESTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
[~~| is [71 is not

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

2. If the Disclosing Party IS afinancialinstitution, then the Disclosing Party pledges:

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

Ver.2018-1 Page 7 of 15
If tiie Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best ofthe Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have afinancialinterest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes |7] No

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

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

Does the Matter involve a City Property Sale?

• Yes 17] No

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

^ 11. The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits
from slavery or slaveholder insurance policies during the slavery era (including insurance policies
issued to slaveholders that provided coverage for damage to or injury or death of their slaves), and
the Disclosing Party has found no such records.

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

SECTION VI ~ CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a member of Congress, in cormection 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.

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

4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) ofthe Internal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) ofthe Internal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.

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 subconttactors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[7] Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60r2.)
• Yes [7] No

2. Have you filed with the Joint Reporting Committee, the Director ofthe Office of Federal Conttact
Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the
applicable filing requirements?
I I Yes • No [7]Reports not required

3. Have you participated in any previous contracts or subcontracts subject to the

equal opportunity clause?
• Yes [7] No

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

Ver.2018-1 Page 10 of 15
SECTION VH ~ FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

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 cormection 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 Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City conttacts, work, business, or transactions. The full text
of this ordinance and a training program is available on line at vyww.cityofchicago.org/Ethics, and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

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

D. It is the City's policy to make this document available to the public on its Intemet site and/or upon
request. Some or all of the information provided in, and appended to, this EDS may be made publicly
available 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 cormection 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 conttact requires. NOTE: With respect to Matters subject to MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

David Halpern
(Print or type exact legal name of Disclosing Party)

By: ^/fu^/L^fig(^
(Sign here)
David Halpern
(Print or type name of person signing)
Individual
(Print or type title of person signing)

Signed and sworn to before me on (date) December 7, 2018

Cook /-^„„+,,
County, Illinois (state).
OFFICIAL SEAL
PAULA BOEHM
Notary Public - State of Illinois
Notary Public My Commission Expires Apr 8, 2019

Commission expires: (X^jp^l ^ \^0i^

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

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

"Applicable Party" means (1) all executive officers 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% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

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

• Yes |7]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.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

• Yes Q] [Zl Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

[7] N/A - 1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.

This certification shall serve as the affidavit required by MCC Section 2-92-385(c)(1).

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT -
2922-24 NORTH CENTRAL PARK. L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners ofthe Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 Nortii Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. • the Applicant
OR
2. [7] a legal entity currently holding, or anticipated to hold within six months after City action on
the contract,ttansactionor other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name: 2922-24 North Central Park, LLC
OR
3. • a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal name of the entity in which the Disclosing Party holds a right of conttol:

B. Business address ofthe Disclosing Party: 1535 N. Elston Avenue

Chicago, IL 60642

C. Telephone:^^2-251-7120 p^x: 773-489-2580 Email: [email protected]

D. Name of contact person: Benjamin Klopp

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting tiiis EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Page 1 of 15
SECTION H - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

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

N/A

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?

I I Yes • No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
Benjamin Klopp Manager

David Halpern Manager

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a trust, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to submit an EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Benjamin Klopp 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

David Halpern 1535 N. Elston Avenue, Chicago, IL 60642 12.5%

[See Section 11(B)(2) Schedule attached hereto for additional responsive information]

SECTION HI ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or compensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [7] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [/] No

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

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subconttactor, attomey,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subconttactor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.
Thomas R. Raines (Retained); 20 N. Wacker Drive, Suite 556, Chicago, IL 60606; Attorney; $7,000 (estimated)

(Add sheets if necessary)

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

SECTION V CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

I I Yes [/] 0 "'^^ person directly or indirectly owns 10% or more of the Disclosing Party.

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

• Yes • No
B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a contract being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public contract, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency conttacts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of anyfine,fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local) transaction or contract under a
public transaction; a violation of federal or state antitrust statutes; fraud; embezzlement; theft; forgery;
bribery; falsification or destmction of records; making false statements; or receiving stolen property;

c. are not presentiy indicted for, or criminally or civilly charged by, a governmental entity (federal,
state or local) with committing any of the offenses set forth in subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions conceming
environmental violations, instituted by the City or by the federal govemment, any state, or any other
unit of local govemment.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• 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: conttols 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 govemment,
including the City, using substantially the same management, ovmership, 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 Conttactor 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 Conttactor or any Affiliated Entity (collectively "Agents").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Contractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Conttactor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years
before the date of such Conttactor's or Affiliated Entity's conttact or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee of the City, the State of Illinois, or any agency of the federal govemment
or of any state or local govemment 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 resttaint of freedom of competition by agreement to bid a fixed price or otherwise; or

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

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "conttolling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii)
the Applicant understands and acknowledges that compliance with Article I is a continuing requirement
for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliance timeframes in this Section V.

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

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

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

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

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

13. 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 $25 per recipient, or (iii) a
political contribution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCL\L INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
I I is [71 is not

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

2. If the Disclosing Party IS a fmancial institution, then the Disclosing Party pledges:
"We are not and will not become a predatory lender as defined in MCC Chapter 2-32. We further
pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in
MCC Chapter 2-32. We understand that becoming a predatory lender or becoming an affiliate of a
predatory lender may result in the loss of the privilege of doing business with the City."

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the same meanings if used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have afinancialinterest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes |7] No

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

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

Does the Matter involve a City Property Sale?

• Yes [7] No

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSESESS

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

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

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

SECTION VI - CERTIFICATIONS FOR FEDERALLY FUNDED MATTERS

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

A. CERTIFICATION REGARDING LOBBYING

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

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

2. The Disclosing Party has not spent and will not expend any federally appropriated fimds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or attempt to influence an officer or employee of any agency, as defined
by applicable federal law, a member of Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a member of Congress, in connection with the award of any federally funded conttact, 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.

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," as that term is defined in the Lobbying Disclosure Act of 1995, as amended.

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 subconttactors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Applicant?

[7] Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes [7] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Conttact
Compliance Programs, or the Equal Employment Opportunity Commission all reports due under the
applicable filing requirements?
I I Yes • No [7|Reports not required

3. Have you participated in any previous contracts or subcontracts subject to the

equal opportunity clause?
• Yes [7] No

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

Ver.2018-1 Page 10 of 15
SECTION VH - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will become part of any
conttact 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 Ordinance, MCC Chapter 2-156, imposes certain duties and
obligations on persons or entities seeking City conttacts, work, business, orttansactions.The full text
of this ordinance and a training program is available on line at vyw w. cityof Chicago. org/Ethics, and may
also be obtained from the City's Board of Etiiics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Party must comply fully with this ordinance.

C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate,
any contract 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 declining to allow the Disclosing Party to participate in other Cityttansactions.Remedies at
law for a false statement of material fact may include incarceration and an award to the City of treble
damages.

D. It is the City's policy to make this document available to the public on its Intemet site and/or upon
request. Some or all ofthe information provided in, and appended to, this EDS may be made publicly
available on the Internet, in response to a Freedom of Information Act request, or otherwise. By
completing and signing this EDS, the Disclosing Party waives and releases any possible rights or
claims which it may have against the City in cormection 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 conttact requires. NOTE: With respect to Matters subject to MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
information provided herein regarding eligibility must be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

Benjamin D. Klopp

(Sign here)
Benjamin D. Klopp
(Print or type name of person signing)
Individual
(Print or type titie of person signing)

Signed and swom to before me on (date) December 7, 2018

at Cook County, '"'"Q'S (state).

OFFICIAL SEAL
Notary Public PAULA BOEHM
Notary Public - State of Illinois
My Commission Expires Apr 8, 2019

Commission expires:

Ver.2018-1 Page 12 of 15
'i-. J.
p... i
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial
relationship" with any elected city official or department head. A "familial relationship" exists if, as of
the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Domestic
Partner thereof is related to the mayor, any alderman, the city clerk, the citytteasureror 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 ofthe Disclosing Party, if the
Disclosing Party is a limited partnership; all managers, managing members and members of the
Disclosing Party, if the Disclosing Party is a limited liability company; (2) all principal officers ofthe
Disclosing Party; and (3) any person having more than a 7.5% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
financial officer, treasurer or secretary of a legal entity or any person exercising similar authority.

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

• Yes 0 No
If yes, please identify below (1) the name and title of such person, (2) the name of the legal entity to
which such person is connected; (3) the name and title ofthe elected city official or department head to
whom such person has a familial relationship, and (4) the precise nature of such familial relationship.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity publiclyttadedon any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes • No [7] The Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (vmw.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Applicant that is a contractor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-385(b)(1) and (2), which prohibit: (i) screening
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

[71 N/A - 1 am not an Applicant that is a "contractor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
2922-24 NORTH CENTRAL PARK, L L C
SCHEDULES

(1) Schedule 11(B)(2): Additional Owners ofthe Applicant

Name Business Address Percentage Interest in Applicant

Robert Deck 1535 North Elston Ave., Chicago, IL 60642 12.5%
Scott Spidale 1535 North Elston Ave., Chicago, IL 60642 12.5%
John C. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
Peter T. Wall 1535 North Elston Ave., Chicago, IL 60642 25%
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

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

Zdzislaw Sitarz

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [•] the Applicant
OR
2. • a legal entity currentiy holding, or anticipated to hold within six months after City action on
the conttact, ttansaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect interest in excess of 7.5% in the Applicant. State the Applicant's legal
name:
OR
3. • a legal entity with a direct or indirect right of control of the Applicant (see Section 11(B)(1))
State the legal narae of the entity in which the Disclosing Party holds a right of control:

B. Business address of the Disclosing Party: 3609 W. Oakdale Avenue

Chicago, IL 60618

C. Telephone: 773-342-4784 pax: Email:

D. Name of contact person: Zdzislaw Sitarz

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change the zoning at 2922-24 N. Central Park Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or department is requesting this EDS? Planning & Development

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

Specification # and Contract #

Ver.2018-1 Paget of 15
SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

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

N/A

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?

I I Yes •No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

NOTE: Each legal entity listed belowraustsubmit an EDS on its own behalf.

Narae Titie
N/A

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

Ver.2018-1 Page 2 of 15
limited liability company, or interest of a beneficiary of a tmst, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed below may be required to subraitan EDS on its own behalf.

Name Business Address Percentage Interest in the Applicant

Zdzislaw Sitarz 3609 W. Oakdale Avenue, Chicago, IL 60618 50%

Stanislawa Sitarz 3609 W. Oakdale Avenue, Chicago, IL 60618 50%

SECTION III " INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY E L E C T E D

OFFICIALS

Has the Disclosing Party provided any income or corapensation to any City elected official during the
12-month period preceding the date of this EDS? • Yes [•] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes [•] No

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

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

SECTION IV - DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subcontractor, attorney,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature of the relationship, and 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. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subconttactor, attorney, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "t.b.d." is
not an acceptable response.

(Add sheets if necessary)

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

SECTION V -- CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

Under MCC Section 2-92-415, substantial owners of business entities that conttact with the City must
reraain 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?

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

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

• Yes No

B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a conttact being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affihated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public conttact, the services of an integrity monitor, independent private sector
inspector general, or integrity corapliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other similar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency contracts in the future, or continue with a contract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018- Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all of those persons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered against them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local)ttansactionor conttact under a
publicttansaction;a violation of federal or state antitrust statutes; fraud; embezzleraent; theft; forgery;
bribery; falsification or destruction of records;raakingfalse stateraents; 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 subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more public transactions
(federal, state or local) terminated for cause or default; and

e. have not, during the 5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions concerning
environmental violations, instituted by the City or by the federal government, any state, or any other
unit of local govemment.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concern:

• the Disclosing Party;
• any "Contractor" (meaning any conttactor or subconttactor 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 Subconttactors 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 conttol of another person or entity). Indicia of conttol 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 ineUgibihty of a business entity to do business with federal or state or local government,
including the City, using substantially the same manageraent, ownership, or principals as the
ineligible entity. With respect to Conttactors, the terra Affiliated Entityraeansa person or entity
that directly or indirectly conttols the Conttactor, is conttolled by it, or, with the Contractor, is
under common conttol of another person or entity;
• any responsible official of the Disclosing Party, any Contractor or any Affiliated Entity or any
other official, agent or eraployee 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").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosing
Party or any Conttactor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Contractor, an Affiliated Entity, or an Affiliated Entity of a Contractor during the 5 years
before the date of such Conttactor's or Affiliated Entity's contract or engageraent 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 eraployee 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 subparagraph (a) or (b) above that is a matter of
record, but have not been prosecuted for such conduct; or

d. violated the provisions referenced in MCC Subsection 2-92-320(a)(4)(Contracts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimura Wage Ordinance).

6. Neither the Disclosing Party, nor any Affiliated Entity or Conttactor, 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.

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions List maintained by the
United States Department of Coraraerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) Neither the Applicant nor any "conttolling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currentiy indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee of the City or any "sister agency"; and (ii)
the Applicant understands and acknowledges that compliance with Article I is a continuing requirement
for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliancetimefraraesupersedes 5-year compliancetimeframesin this Section V.

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

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

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

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

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

13. 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
raade generally available to City eraployees or to the general public, or (ii) food or drink provided in
the course of official City business and having a retail value of less than $25 per recipient, or (iii) a
political conttibution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the narae of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

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

• is 0
a "financial institution" as defined in MCC Section 2-32-455(b).

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 MCC Chapter 2-32. We further
pledge that none of our affiliates is, and none of them will become, a predatory lender as defined in
MCC Chapter 2-32. We understand that becoraing a predatory lender or becoraing an affiliate of a
predatory lender may result in the loss of the privilege of doing business with the City."

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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 stateraents.

D. CERTIFICATION REGARDING FINANCIAL INTEREST IN CITY BUSINESS

Any words or terras defined in MCC Chapter 2-156 have the sameraeaningsif used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or employee of the City have a financial interest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes [•] No

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

2. Unless sold pursuant to a process of competitive bidding, or otherwise perraitted, no City elected
official or eraployee 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 afinancialinterest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

• Yes [^jNo

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDING SLAVERY ERA BUSINESS

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

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

I I 2. The Disclosing Party verifies that, as a result of conducting the search in step (1) above, the
Disclosing Party has found records of investraents or profits frora slavery or slaveholder insurance
policies. The Disclosing Party verifies that the following constitutes full disclosure of all such
records, including the naraes 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, coraplete 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, as amended, who have made lobbying contacts on behalf of the Disclosing
Party with respect to the Matter: (Add sheets if necessary):
N/A

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

2. The Disclosing Party has not spent and will not expend any federally appropriated funds to pay
any person or entity listed in paragraph A(l) above for his or her lobbying activities or to pay any
person or entity to influence or atterapt to influence an officer or employee of any agency, as defined
by applicable federal law, a meraber of Congress, an officer or eraployee of Congress, or an employee
Ver.2018-1 Page 9 of 15
of a member of Congress, in connection with the award of any federally funded contract, making any
federally funded grant or loan, entering into any cooperative agreement, or to extend, continue, renew,
amend, or modify any federally funded contract, grant, loan, or cooperative agreement.

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 inforraation 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," as that terra is defined in the Lobbying Disclosure Act of 1995, as amended.

5. If the Disclosing Party is the Applicant, the Disclosing Partyraustobtain certifications equal in
forra and substance to paragraphs A(l) through A(4) above frora all subconttactors before it awards
any subcontract and the Disclosing Partyraustraaintainall such subcontractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

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

Is the Disclosing Party the Apphcant?

[•] Yes • No

If "Yes," answer the three questions below:

1. Have you developed and do you have on file affirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes !•] No

2. Have you filed with the Joint Reporting Committee, the Director of the Office of Federal Contract
Compliance Programs, or the Equal Eraployraent Opportunity Coraraission all reports due under the
applicable fiUng requirements?
I I Yes • No Reports not required

3. Have you participated in any previous contracts or subcontracts subject to the

equal opportunity clause?
• Yes 121 No
If you checked "No" to question (1) or (2) above, please provide an explanation:
N/A

Ver.2018-1 Page 10 of 15
SECTION VII - FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will becorae part of any
conttact 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 conttact 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 Ordinance, MCC Chapter 2-156, iraposes certain duties and
obligations on persons or entities seeking City conttacts, work, business, orttansactions.The full text
of this ordinance and a training program is available on line at www.cityofchicago.org/Ethics. and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Partyraustcomply fully with this ordinance.

C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate,
any conttact 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 conttact or agreement (if not rescinded or
void), at law, or in equity, including terminating the Disclosing Party's participation in the Matter
and/or declining to allow the Disclosing Party to participate in other City ttansactions. Remedies at
law for a false statement of material fact may include incarceration and an award to the City of tteble
daraages.

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 in, and appended to, this EDS may beraadepublicly
available on the Internet, in response to a Freedora of Inforraation 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 raust 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 Departraent of Procurement Services, the Disclosing Party must
update this EDS as the contract requires. NOTE: With respect to Matters subject to MCC Chapter
1-23, Article I (imposing PERMANENT INELIGIBILITY for certain specified offenses), the
inforraation provided herein regarding eligibility raust be kept current for a longer period, as required
by MCC Chapter 1-23 and Section 2-154-020.

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

ZDZISLAW SITARZ
(Print or, type exact legal name of Disclosing Party)

By: T^MMAT AjbuLy

(Sien
(Sign here) /
ZDZISLAW SITARZ
(Print or type name of person signing)
PROPERTY OWNER
(Print or type title of person signing)

Signed and sworn to before me on (date) January 15, 2019

at Cook ^ County, '"'"Q'S (state).

OFFICIAL SEAL
PAULA BOEHM
Notary Public Notary Public - State of Illinois
My Commission Expires Apr 8, 2019

Commission expires:

Ver.2018-1 Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH E L E C T E D CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial
relationship" with any elected city official or department head. A "familial relationship" exists if, as of
the date this EDS is signed, the Disclosing Party or any "Applicable Party" or any Spouse or Doraestic
Partner thereof is related to theraayor,any alderman, the city clerk, the citytteasureror any city
department head as spouse or doraestic 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 hsted 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; allraanagers,raanagingmembers and members of the
Disclosing Party, if the Disclosing Party is a limited liability corapany; (2) all principal officers of the
Disclosing Party; and (3) any person havingraorethan a 7.5% ownership interest in the Disclosing
Party. "Principal officers" means the president, chief operating officer, executive director, chief
financial officer,tteasureror 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 "farailial relationship" with an elected city official or department head?

• Yes • No
If yes, please identify below (1) the name and title of such person, (2) the name 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.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes • No
2. If the Applicant is a legal entity publicly traded on any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes n [[] Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "contractor" as
defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.com),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing thera to conduct a business on
City premises.

On behalf of an Applicant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in corapliance with MCC Section 2-92-385(b)(l) and (2), which prohibit: (i) screening
job apphcants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former employers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

I I N/A - 1 ara not an Applicant that is a "conttactor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT
AND AFFIDAVIT

SECTION I - GENERAL INFORMATION

A. Legal name ofthe Disclosing Party submitting this EDS. Include d^/a/ if apphcable:
Stanislawa Sitarz

Check ONE of the following three boxes:

Indicate whether the Disclosing Party submitting this EDS is:

1. [•] the Applicant
OR
2. • a legal entity currently holding, or anticipated to hold within six months after City action on
the conttact, ttansaction or other undertaking to which this EDS pertains (referred to below as the
"Matter"), a direct or indirect intereist in excess of 7.5% in the Applicant. State the Applicant's legal
narae:
OR
3. • a legal entity with a direct or indirect right of conttol of the Applicant (see Section 11(B)(1))
State the legal name oftiieentity in which the Disclosing Party holds a right of conttol;

B. Business address of the Disclosmg Party: 3609 W. Oal<da!e Avenue

Chicago, IL 60618

C. Telephone: 773-342-4784 pax: Email:

D. Name of contact person: Stanislawa Sitarz

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

F. Brief description of the Matter to which this EDS pertains. (Include project number and location of
property, if applicable):
Application for a zoning amendment to change tiie zoning at 2922-24 N. Central Parl< Ave. / 3609 W. Oakdale Ave. to a C1-3.

G. Which City agency or departtnent is requesting tiiis EDS? Planning & Development

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

Specification # and Conttact #

Ver.2018-1 Paget of 15
 SECTION II - DISCLOSURE OF OWNERSHIP INTERESTS

A. NATURE OF THE DISCLOSING PARTY

1. Indicate the nature of the Disclosing Party:

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

2. For legal entities, the state (or foreign countty) of incorporation or organization, if applicable:
N/A

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

• Yes •No • Organized in Illinois

B. IF THE DISCLOSING PARTY IS A LEGAL ENTITY:

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

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

Name Title
N/A

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

Ver.2018-1 Page 2 of 15
limited liabihty company, or interest of a beneficiary of a tmst, estate or other similar entity. If none,
state "None."

NOTE: Each legal entity listed belowraaybe required to subrait an EDS on its own behalf

Name Business Address Percentage Interest in the Applicant

Zdzislaw Sitarz 3609 W. Oakdale Avenue, Chicago, IL 60618 50%

Stanislawa Sitarz 3609 W. Oakdale Avenue, Chicago, IL 60618 50%

SECTION III ~ INCOME OR COMPENSATION TO, OR OWNERSHIP BY, CITY ELECTED

OFFICIALS

Has the Disclosing Party provided any income or corapensation to any City elected official during the
12-montii period preceding the date of this EDS? • Yes [•] No

Does the Disclosing Party reasonably expect to provide any income or compensation to any City
elected official during the 12-month period following the date of this EDS? • Yes 0 No

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

Does any City elected official or, to the best of the Disclosing Party's knowledge after reasonable
inquiry, any City elected official's spouse or domestic partner, have a financial interest (as defmed in
Chapter 2-156 ofthe Municipal Code of Chicago ("MCC")) in the Disclosing Party?
• Yes !•] No

If "yes," please identify below the name(s) of such City elected official(s) and/or spouse(s)/domestic
partner(s) and describe thefinancialinterest(s).

SECTION rV ~ DISCLOSURE OF SUBCONTRACTORS AND OTHER RETAINED PARTIES

The Disclosing Party must disclose the name and business address of each subconttactor, attomey,
lobbyist (as defined in MCC Chapter 2-156), accountant, consultant and any other person or entity
whom the Disclosing Party has retained or expects to retain in connection with the Matter, as well as
the nature ofthe relationship, and the total amount ofthe fees paid or estimated to be paid. The
Disclosing Party is not required to disclose employees who are paid solely through the Disclosing
Party's regular payroll. 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.

Ver.2018-1 Page 3 of 15
Name (indicate whether Business Relationship to Disclosing Party Fees (indicate whether
retained or anticipated Address (subcontractor, attomey, paid or estimated.) NOTE:
to be retained) lobbyist, etc.) "hourly rate" or "tb.d." is
not an acceptable response.

(Add sheets if necessary)

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

SECTION V ~ CERTIFICATIONS

A. COURT-ORDERED CHILD SUPPORT COMPLIANCE

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

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

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

• Yes l^jNo
B. FURTHER CERTIFICATIONS

1. [This paragraph 1 applies only if the Matter is a conttact being handled by the City's Department of
Procurement Services.] In the 5-year period preceding the date of this EDS, neither the Disclosing
Party nor any Affiliated Entity [see definition in (5) below] has engaged, in connection with the
performance of any public conttact, the services of an integrity monitor, independent private sector
inspector general, or integrity compliance consultant (i.e., an individual or entity with legal, auditing,
investigative, or other sirailar skills, designated by a public agency to help the agency monitor the
activity of specified agency vendors as well as help the vendors reform their business practices so they
can be considered for agency conttacts in the future, or continue with a confract in progress).

2. The Disclosing Party and its Affiliated Entities are not delinquent in the payment of any fine, fee,
tax or other source of indebtedness owed to the City of Chicago, including, but not limited to, water
and sewer charges, license fees, parking tickets, property taxes and sales taxes, nor is the Disclosing
Party delinquent in the payment of any tax administered by the Illinois Department of Revenue.

Ver.2018-1 Page 4 of 15
3. The Disclosing Party and, if the Disclosing Party is a legal entity, all offliosepersons or entities
identified in Section 11(B)(1) of this EDS:

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

b. have not, during the 5 years before the date of this EDS, been convicted of a criminal offense,
adjudged guilty, or had a civil judgment rendered agamst them in connection with: obtaining,
attempting to obtain, or performing a public (federal, state or local)ttansactionor conttact under a
publicttansaction;a violation of federal or state antitmst statutes;fi-aud;embezzlement; theft; forgery;
bribery; falsification or destmction of records; making false statements; or receiving stolen property;

c. are not presently indicted for, or criminally or civilly charged by, a govemraental entity (federal,
state or local) with comraitting any ofthe offenses set forth in subparagraph (b) above;

d. have not, during the 5 years before the date of this EDS, had one or more pubUc ttansactions
(federal, state or local) terminated for cause or default; and

e. have not, duringtiie5 years before the date of this EDS, been convicted, adjudged guilty, or found
liable in a civil proceeding, or in any criminal or civil action, including actions conceming
environmental violations, instituted by the City or by the federal govemment, any state, or any other
unit of local government.

4. The Disclosing Party understands and shall comply with the applicable requirements of MCC
Chapters 2-56 (Inspector General) and 2-156 (Governmental Ethics).

5. Certifications (5), (6) and (7) concem:

• the Disclosing Party;
• any "Contractor" (meaning any contractor or subconttactor used by the Disclosing Party m
connection with the Matter, mcluding but not limited to all persons or legal entities disclosed
under Section IV, "Disclosure of Subcontractors and Other Retained Parties");
• any "Affihated Entity" (meaning a person or entity that, directly or indirectly: conttols the
Disclosing Party, is confrolled by the Disclosing Party, or is, with the Disclosing Party, under
common control of another person or entity). Indicia of confrol include, without limitation:
interlocking management or ownership; identity of interests araong family members, shared
facilities and equipment; common use of employees; or organization of a business entity following
the inehgibility of a business entity to do business with federal or state or local govemment,
including the City, using substantially the same manageraent, ownership, or principals as the
ineligible entity. With respect to Confractors, the term Affiliated Entity means a person or entity
that directiy or indirectly confrols the Confractor, is controlled by it, or, with the Confractor, is
under common confrol of another person or entity;
• any responsible official of the Disclosing Party, any Confractor 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 Confractor or any Affiliated Entity (collectively "Agents").

Ver.2018-1 Page 5 of 15
Neither the Disclosing Party, nor any Contractor, nor any Affiliated Entity of either the Disclosmg
Party or any Confractor, nor any Agents have, during the 5 years before the date of this EDS, or, with
respect to a Confractor, an Affiliated Entity, or an Affiliated Entity of a Confractor during the 5 years
before the date of such Confractor's or Affiliated Entity's contract or engagement in connection with the
Matter:

a. bribed or attempted to bribe, or been convicted or adjudged guilty of bribery or attempting to bribe,
a public officer or employee of the City, the State of Illinois, or any agency of the federal govemment
or of any state or local govemment 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 resttaint offi-eedomof competition by agreement to bid afixedprice or otherwise; or

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

d. violatedtiieprovisions referenced in MCC Subsection 2-92-320(a)(4)(Conttacts Requiring a Base

Wage); (a)(5)(Debarment Regulations); or (a)(6)(Minimum Wage Ordinance).

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

7. Neither the Disclosing Party nor any Affiliated Entity is listed on a Sanctions Listraaintainedby the
United States Department of Commerce, State, or Treasury, or any successor federal agency.

8. [FOR APPLICANT ONLY] (i) NeitiiertiieApplicant nor any "controlling person" [see MCC
Chapter 1-23, Article I for applicability and defined terms] of the Applicant is currently indicted or
charged with, or has admitted guilt of, or has ever been convicted of, or placed under supervision for,
any criminal offense involving actual, attempted, or conspiracy to commit bribery, theft, fraud, forgery,
perjury, dishonesty or deceit against an officer or employee ofthe City or any "sister agency"; and (ii)
the Applicant understands and acknowledges that compliance with Article I is a continuing requirement
for doing business with the City. NOTE: If MCC Chapter 1-23, Article I applies to the Applicant, that
Article's permanent compliance timeframe supersedes 5-year compliancetimeframesin this Section V.

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

10. [FOR APPLICANT ONLY] The Applicant will obtain frora any contractors/subconttactors hired
or to be hired in cormection with the Matter certifications equal in form and substance to those in
Certifications (2) and (9) above and will not, without the prior written consent of the City, use any such
Ver.2018.1 Page 6 of 15
contractor/subcontractor that does not provide such certifications or that the Applicant has reason to
believe has not provided or cannot provide tmthful certifications.

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

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

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

13. 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 anytimeduring
the 12-month period preceding the execution date of this EDS, to an eraployee, or elected or appointed
official, of the City of Chicago. For purposes of this statement, a "gift" does not include: (i) anything
raade generally available to City eraployees or to the general public, or (ii) food or drink provided in
the course of official City business and having a retail value of less than $25 per recipient, or (iii) a
political conttibution otherwise duly reported as required by law (if none, indicate with "N/A" or
"none"). As to any gift listed below, please also list the name of the City recipient.
NONE

C. CERTIFICATION OF STATUS AS FINANCIAL INSTITUTION

1. The Disclosing Party certifies that the Disclosing Party (check one)
• is 0 ^'^^
a "financial institution" as defined in MCC Section 2-32-455(b).

2. If the Disclosing Party IS afinancialinstitution, then the Disclosing Party pledges:

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

Ver.2018-1 Page 7 of 15
If the Disclosing Party is unable to make this pledge because it or any of its affiliates (as defined in
MCC Section 2-32-455(b)) is a predatory lender within the meaning of MCC Chapter 2-32, explain
here (attach additional pages if necessary):
N/A

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

D. CERTIFICATION REGARDESiG FINANCIAL INTEREST IN CITY BUSINESS

Any words or terms defined in MCC Chapter 2-156 have the sameraeaningsif used in this Part D.

1. In accordance with MCC Section 2-156-110: To the best of the Disclosing Party's knowledge
after reasonable inquiry, does any official or eraployee of the City have afinancialinterest in his or
her own name or in the name of any other person or entity in the Matter?

• Yes I^No
NOTE: If you checked "Yes" to Item D(l), proceed to Iteras D(2) and D(3). If you checked "No"
to Itera D(l), skip Iteras D(2) and D(3) and proceed to Part E.

2. Unless sold pursuant to a process of competitive bidding, or otherwise permitted, no City elected
official or eraployee shall have afinancialinterest 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 emment domain
power does not constitute a fmancial interest within the meaning of this Part D.

Does the Matter involve a City Property Sale?

• Yes [TjNo

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

Name Business Address Nature of Financial Interest

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

Ver.2018-1 Page 8 of 15
E. CERTIFICATION REGARDESfG SLAVERY ERA BUSINESS

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

_ • The Disclosing Party verifies that the Disclosing Party has searched any and all records of
the Disclosing Party and any and all predecessor entities regarding records of investments or profits
frora slavery or slaveholder insurance policies durmg the slavery era (includmg 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 fiill 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 ofthe City are not federal funding.

A. CERTIFICATION REGARDING LOBBYING

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

(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 imder the Lobbying Disclosure Act of 1995, as amended, haveraadelobbying 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 appropriatedfimdsto 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 eraployee of any agency, as defined
by applicable federal law, araemberof Congress, an officer or employee of Congress, or an employee
Ver.2018-1 Page 9 of 15
 of a member of Congress, in connection with the award of any federally funded confract, 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.

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 inforraation set
forth in paragraphs A(l) and A(2) above.

4. The Disclosing Party certifies that either: (i) it is not an organization described in section
501(c)(4) of the Intemal Revenue Code of 1986; or (ii) it is an organization described in section
501(c)(4) of the Intemal Revenue Code of 1986 but has not engaged and will not engage in "Lobbying
Activities," as that terra is defined in the Lobbying Disclosure Act of 1995, as araended.

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 subconfractors before it awards
any subconfract and the Disclosing Party must maintain all such subconfractors' certifications for the
duration of the Matter and must make such certifications promptly available to the City upon request.

B. CERTIFICATION REGARDING EQUAL EMPLOYMENT OPPORTUNITY

If the Matter is federally funded, federal regulations require the Applicant and all proposed
subconttactors to subrait the following inforraation with their bids or m writing at the outset of
negotiations.

Is the Disclosing Party the Applicant?

0 Yes • No
If "Yes," answer the three questions below:

1. Have you developed and do you have onfileaffirmative action programs pursuant to applicable
federal regulations? (See 41 CFR Part 60-2.)
• Yes [•] No

2. Have youfiledwith the Joint Reporting Committee, the Director of the Office of Federal Conttact
Compliance Prograras, or the Equal Eraployraent Opportunity Coraraission all reports due under the
applicablefilingrequirements?
1 I Yes • No [^Reports not required

3. Have you participated in any previous conttacts or subconttacts subject to the

equal opportunity clause?
• Yes g'No

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

Ver.2018-1 Page 10 of 15
 SECTION VII ~ FURTHER ACKNOWLEDGMENTS AND CERTIFICATION

The Disclosing Party understands and agrees that:

A. The certifications, disclosures, and acknowledgments contained in this EDS will becorae part of any
conttact or other agreeraent 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 conttact 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 Govemraental Ethics Ordinance, MCC Chapter 2-156, iraposes certain duties and
obligations on persons or entities seeking City conttacts, work, business, or transactions. The full text
of this ordinance and attainingprogram is available on line at www.cityofchicago.org/Ethics. and may
also be obtained from the City's Board of Ethics, 740 N. Sedgwick St., Suite 500, Chicago, IL 60610,
(312) 744-9660. The Disclosing Partyraustcomply fully with this ordinance.

C. If the City determines that any information provided in this EDS is false, incomplete or inaccurate,
any conttact 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 confract 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 Cityfransactions.Remedies at
law for a false statement of material fact may include incarceration and an award to the City of freble
daraages.

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 in, and appended to, this EDS may be made publicly
available on the Internet, in response to a Freedom of Information Act request, or otherwise. By
completing and signing this EDS, the Disclosing Party waives and releases any possible rights or
claims which it may have against the City in connection with the public release of information
contained in this EDS and also authorizes the City to verify the accuracy of any information submitted
in this EDS.

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

Ver.2018-1 Page 11 of 15
CERTIFICATION

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

STANISLAWA SITARZ
(Print or type exact legal name of Disclosing Party)

)ign here)

STANISLAWA SITARZ
(Print or type name of person signing)
PROPERTY OWNER
(Print or type title of person signing)

Signed and swom to before me on (date) January 15, 2019

at Cook Illinois (state).

Notary Public

Commission expires: O^ J^Kll f 7/<3| ^

Ver.2018-i Page 12 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX A

FAMILIAL RELATIONSHIPS WITH ELECTED CITY OFFICIALS

AND DEPARTMENT HEADS

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

Under MCC Section 2-154-015, the Disclosing Party must disclose whether such Disclosing Party
or any "Applicable Party" or any Spouse or Domestic Partner thereof currently has a "familial
relationship" with any elected city official or departraent head. A "familial relationship" exists if, as of
the date this EDS is signed, the Disclosing Party or any "AppUcable Party" or any Spouse or Domestic
Partner thereof is related to the mayor, any alderman, the city clerk, the citytteasureror 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; allraanagers,raanagingraembersandraerabersof the
Disclosing Party, if the Disclosmg Party is a hmited liability company; (2) all principal officers of the
Disclosing Party; and (3) any person having more than a 7.5% ovmership interest in the Disclosing
Party. 'Principal officers"raeansthe president, chief operating officer, executive director, chief
financial officer,tteasureror secretary of a legal entity or any person exercising sirailar authority.

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

• Yes l^jNo
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 departraent head to
whora such person has a familial relationship, and (4) the precise nature of such familial relationship.

Ver.2018-1 Page 13 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX B

BUILDING CODE SCOFFLAW/PROBLEM LANDLORD CERTIFICATION

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

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

• Yes 0 No
2. If the Applicant is a legal entity publiclyttadedon any exchange, is any officer or director of
the Applicant identified as a building code scofflaw or problem landlord pursuant to MCC Section
2-92-416?

I I Yes O No j^J The Applicant is not publicly traded on any exchange.

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

Ver.2018-1 Page 14 of 15
 CITY OF CHICAGO
ECONOMIC DISCLOSURE STATEMENT AND AFFIDAVIT
APPENDIX C

PROHIBITION ON WAGE & SALARY HISTORY SCREENING - CERTIFICATION

This Appendix is to be completed only by an Applicant that is completing this EDS as a "conttactor" as
defined in MCC Section 2-92-385. That section, which should be consulted (www.amlegal.cora),
generally covers a party to any agreement pursuant to which they: (i) receive City of Chicago funds in
consideration for services, work or goods provided (including for legal or other professional services),
or (ii) pay the City money for a license, grant or concession allowing them to conduct a business on
City premises.

On behalf of an Apphcant that is a conttactor pursuant to MCC Section 2-92-385,1 hereby certify that
the Applicant is in compliance with MCC Section 2-92-3 85(b)(1) and (2), which prohibit: (i) screenmg
job applicants based on their wage or salary history, or (ii) seeking job applicants' wage or salary
history from current or former eraployers. I also certify that the Applicant has adopted a policy that
includes those prohibitions.

• Yes

• No

{•I N/A - 1 am not an Applicant that is a "conttactor" as defined in MCC Section 2-92-385.

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

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

Ver.2018-1 Page 15 of 15