D i sc l osure Summa r y Shee t

Con t rac t (PO) Numbe r : C029725


Spec i f i ca t i on Numbe r : C968990037


Name of ...
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JUN    10    2003        10 : 04RM           HP     LF I SERJET         3200                                              ...
ADDENDUM TO D I SCLOSURE AFF I DAVI T


Cer t i f i ca t i on Rega rd i ng S l avery Era Bus i ness
Con t r ac t o r - - -...
ADDENDUM TO D ISCLOSURE AFF IDAVIT
B_         The Con t r ac t o r s oo i rga t i on t o pay. anC To a= r e pcaymr n t o f...
Spec i f i ca t i on No , : C92S990002
                                                                      Pre -Quah f t...
Spec i f i ca t i on No . : C925-99-0025
                                                                             Pre-...
UE i / 24 / 2UU3 12 : 58 FAX 312             220 0722                                                                     ...
SECT I ON ONE : D I SCLOSURE OF OWNERSH I P I NTERESTS

             NATURE OF ENTI TY

              Indi cate whe ther t...
2.          IF THE UNDERS I GNED IS A PARTNERSH I P :
For genera l or l imi ted par tnersh i ps : l ist be l ow the name ,...
SECT I ON TWO : BUS I NESS RELAT I ONSH I PS W I TH CITY ELECTED OFF ICIALS
A.         DEF IN ITIONS AND D I SCLOSURE REQU...
06 / 24 / 2003 12 : 58 FAX 312 220 0722                                                                                   ...
B.         The App l i cant and i ts af f i l iates have not , in the past f ive years , been found in violat ion of any C...
III .         FURTHER CERT I F I CAT I ONS

A.            The App l i cant and , if the App l i cant is a l ega l ent i ty...
D.          Ne i ther the App l i cant nor any emp l oyee , of f icial , agent or par tner of the App l i cant is bar red ...
2.           Un l ess so ld pursuant to a process of compet i t i ve bidding, no Ci ty e l ected of f icial or emp l oyee ...
I.           CERTI F I CATI ON REGARD I NG LOBBYI NG

A.            List be l ow the names of al l persons regi stered und...
C.           The App l i cant wi l l forward the not i ce set for th be l ow to proposed subcont ractors:

             NO...
B.          The cont ractor ' s obl igat ion to pay , and to assure payment of , the Base Wage wi l l beg i n a t any t i ...
5)            Prov i de that Ci ty emp l oyees and of f icials, or the i r spouses or mi nor chi ldren, cannot rece i ve c...
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                             ...
JUN   10        e~UU3      10 : U4r , i - ,       HP   LRSERJET          3200




      4.             The Con t rac tor u...
RrRN TH I S " D I SCLOSURE OF RETA I NED PART I ES "
                                   FORM W I TH I N 7 CALENDAR DAYS OF...
The Cont rac tor unders t a i          and agrees as fo l l ows .

          a . The i n forma t i on prov i ded here i n ...
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Contract # C029725: Patrick Engineering Contract with City of Chicago

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Contract # C029725: Patrick Engineering Contract with City of Chicago

  1. 1. D i sc l osure Summa r y Shee t Con t rac t (PO) Numbe r : C029725 Spec i f i ca t i on Numbe r : C968990037 Name of Con t rac t or : PATR I CK ENG I NEER I NG I NC C i t y Depa r t men t : CH I CAGO DEPARTMENT OF TRANSPORTAT I ON T i t l e of Con t rac t : PN84CO29725 PROFESS I ONAL (Te rm of Con t r ac t is no t app l i cab l e) Do l l a r Amoun t o f Con t rac t (or max i mum compensa t i on i f a Te rm Agr eemen t ) : $4 , 543 .51 Br i e f Desc r i p t i on of Wo r k : PN84CO29725 PROFESS I ONAL Procur emen t Serv i ces Con t ac t Pe rson : Use r Conve rs i on Vendor Numbe r : 1040749 Subm i ss i opEPa~eo 2003
  2. 2. JUN 10 2003 10 : 04RM HP LASERJET 3200 Spec i f i ca t i on No. : ( - g to $ °) °) O ( ) ,61 ADDENDUM TO D I SCLOSURE AFF I DAV I T CERT I F I CAT I ON REGARD I N G I NTEREST I N C I TY BUS I NESS Any words or t e rms tha t are de f i ned i n Chap t e r 2-156 o f the Ch i cago Mun i c i pa l Code have the same mean i ngs when used i n th i s Cer t i f i ca t i on . Comp l e t e BOTH sec t i ons 1 and 2 . In accordance w i t h Sec t i on 2-156-110 o f the Mun i c i pa l Code of Ch i cago : 1 . Does any of f i c i a l or emp l oyee o f the C i t y o f Ch i cago have a f i nanc i a l i nt erest i n h i s or he r own name or i n the name o f any o ther pe rson i n th i s cont rac t , won t , bus i ness , or t ransac t i on? X No. Yes . I f yes , i dent i f y the of f i c i a l s or emp l oyees hav i ng such i nterest and the na ture o f such i nterest : 2. Un l ess so l d pursuan t to a process o f compe t i t i ve b i dd i ng , no of f i c i a l or emp l oyee sha l l have a f i nanc i a l i nt erest i n h i s or he r own name or i n the name o f any other pe rson i n t he purchase o f any proper t y tha t ( i ) be l ongs to the c i ty , or ( i i ) i s so l d for t axes or assessment s , or ( i i i ) i s so l d ' % v i r tue o f l ega l process at the su i t o f the c i ty (co l l ec t i ve l y , " C i t y Proper t y Sa l e " ) . Compensa t i on for proper t y t aken pursuant to the c i ty ' s em i nen t doma i n powe r does no t const i tut e a f i nanc i a l i nterest w i th i n the mean i ng o f th i s sec t i on . I f the cont rac t , wor k , bus i ness , or t ransac t i on i nvo l ves a C i t y Prope r t y Sa l e does any of f i c i a l or emp l oyee have a f i nanc i a l i nt erest i n h i s or he r own name or i n t he name o f any other pe rson i n the C i t y Proper t y Sa l e? XN / A ( i .e. , the cont rac t , wor k , bus i ness , or t ransac t i on i s not for a C i t y Proper t y Sa l e) No . Yes . I f yes , i dent i f y t he of f i c i a l s or emp l oyees hav i ng such i nterest and t he na ture o f such i nterest : 3. 1 fur ther cer t i fy tha t no such f i nanc i a l i nterest i n th i s cont rac t , wor k , bus i ness , or t ransac t i on w i l l be acqu i red by any of f i c i a l or emp l oyee o f t he C i t y o f Ch i cago. Unde r pena l t y o f per j ury , I cer t i f y tha t I am au thor i zed to execu t e th i s Addendum to D i sc l osure Af f i dav i t on beha l f o f the Cont rac tor , that I have persona l know l edge o f the cer t i f i ca t i ons be i ng made i n i t and , tha t they are comp l e t e and t rue SEWo2 yl Ce P2Es r0 f i I S i gna ture qA #ed Of f i cer Ti t le V~ L RC . ~-w 5 31 Z 201 - '7 y 0 0 Z-E Name o f Au t hor i zed Of f i cer (Pr i nt or Type ) Bus i ness Te l ephone Numbe r St a t e o f - - r l l 1 RO I s . Coun t y of Sworn to and acknow l edged be fore me b 7( 4 e W. (name o f s i gna tory) as S - _ J l hp - t ~<2s dn ,Cc t - ' ( t i t l e) o f ck. F t ~ ~, Pt , r (name o f cont rac t i ng par t y) th i s cNr - day of w^-e - , 20Q3 - . -3 Sea l : OFFU2AL SEAL MARTA M OLAQUE 4094Q, No t Ary Pub l i c NOTARY PUOUC - STATE OF I I t aNOS My comm i ss i on exp i res on : MY CO I ~ t OSM EWMES W19A
  3. 3. JUN 10 2003 10 : 04RM HP LF I SERJET 3200 P .6 (A T i e i - -Z E, .~~~,. ~ f f R~~G 1nrL , , ` Con t r ac t or : Con t r ac t No. : f N g y C. o L l 2S Spec i f i cat i on No. : C- (~to $ C-)C5 00 , 31 ACKNOWLEDGMENT Cont rac tor acknow l edges and agrees tha t the fo l l ow i ng prov i s i on is added to and becomes par t of the Cont rac t re f erenced above : BUS I NESS RELAT I ONSH I PS W I TH ELECTED OFF I C I ALS Pursuant to Sec t i on 2-156-030(b) of the Mun i c i pa l Code of the Ci ty of Ch i cago , i t is i l lega l for any e l ec ted of f ic ia l of the c i ty, or any person ac t i ng a t the d i rec t i on of such of f ic ia l , to contac t , e i ther ora l l y or in wr i t ing, any other c i ty of f i c i a l or emp l oyee w i th respec t to 4ny ma t t er i nvo l v i ng any person w i th whom the e l ec t ed of f icial has a bus i ness re l at i onsh i p, or to par t i c i pa t e in any d i scuss i on in any c i ty counc i l comm i t t ee hear i ng or in any c i ty counc i l mee t i ng or to vot e on any ma t t er i nvo l v i ng the person w i th whom an e l ec t ed of f i c i a l has a bus i ness re l a t i onsh i p . V i o l a t i on of Sec t i on 2-156-030(b) by any e l ec t ed of f i c i a l w i th respec t t o th i s cont rac t sha l l be grounds for t erm i na t i on of th i s cont rac t . The t e rm ' bus i ness re l at i onsh i p" is de f i ned as se t for th in Sec t i on 2- - 1 56-0 80 of the Mun i c i pa l Code of Ch i cago. _- Sec t i on 2 . 156-080 de f i nes a " bus i ness re l a t i onsh i p " as anycont rac tua l or other pr i va t e bus i ness dea l i ng of an of f i c i a l , or h i s or her spouse , or of any ent i ty in wh i ch an of f icial or h i s or her spouse has a f inanc i a l interest , w i th a person or ent i ty wh i ch ent i t l es an of f i c i a l to compensa t i on or paymen t in the amoun t of 52 , 500 or more i n a ca l endar year ; prov i ded , however , a f i nanc i a l i nterest sha l l not i nc l ude : ( i ) any owne rsh i p through purchase a t fai r ma rke t va l ue or i nher i t ance of l ess than one percent of the shares of a corpora t i on , or any corpora t e subs i d i ary , parent or af f i l i ate thereof , regard l ess of the va l ue of or d i v i dends on such share , i f such shares are reg i stered on a secur i t i es exchange pursuant to the Secur i t i es Exchange Ac t of 1934 , as amended; (i i) the author i zed compensa t i on pa i d to an of f i c i a l or emp l oyee for hi s of f i ce or emp l oymen t ; ( i i i ) any econom i c benef i t prov i ded equa l l y to al l res i dents of the c i ty; ( iv) a t i me or demand depos i t in a f i nanc i a l inst i tut ion, or (v) an endowmen t or i nsurance po l i cy of annu i t y cont rac t purchased f rom an i nsurance company. A " cont rac tua l or o ther pr i va t e bus i ness dea l i ng " sha l l no t i nc l ude any emp l oymen t re l at i onsh i p of an of f i c i a l 's spouse w i th an ent i ty when such spouse has no d i scre t i on concern i ng or i nput re l at ing to the re l a t i onsh i p be t ween that ent i ty and the c i ty, S I GNED : PPR-19%L-4- E .~aI J"7EER l d& IPJC- . SE - AorL O I LE (KES106 - q Ti t l e Da t e Rev. 12198
  4. 4. ADDENDUM TO D I SCLOSURE AFF I DAVI T Cer t i f i ca t i on Rega rd i ng S l avery Era Bus i ness Con t r ac t o r - - - Pa t r i ck Eng i nee r i ng I nc Pro j ec t No . / Desc . . Pr o f ess i ona l Des i Cons roc r No : PN84CO29725 Spec i f i ca t i on No . : Cq~Q920037 Chap r e r 2 - 92585 o f Tne Mun i c i pQ I Code o f Ch i cdg4 r equ i r es t ha t any en t i t y en t e r i ng i n t o a con t r ac t w i t h The C i t y o f Ch i cago musT comp l e t e an a f f t d0v i T ve r i f y i ng t ha t t he en t i t y has seO r cnea any and a l l r ecords o f me en t i t y and any ana a l l p r edecesso r en t i t i es f or r ecords o f i nves t men t s o r pro f i t s f rom s l ave ry , The s l ave i ndus t ry. or s t aveno l ae r a l sur ance po l i c i es f rom t he s l ave r y e r a ( I nc l ud i ng i nsur ance pa r c i es msue t l t o s l oveho l de ( s t ha t p rov i ded cove r age for gomage t o or i n j ury or dea t h o f t he i r s l aves ] and rnu&T d i sc l ose i n t he Q f f i dava such r ecords To t he C i t y . I n add i t i on. t he o r a i nance r equ i r es Tha t t he en t i t y d i sc l ose i n t he o f f i aav i t t he names OT any s t aves or s l oveho(de r s cyescnbed i n t hose r ecords Fa i l ure t o CQMp l y w i t h t he o r d i nance makes t he con t r ac t vo i c l arb l e on beha l f o f The C i t y . P l ease Check e i The r (1) or (2) I Ne l ovv . I t Tne Con t r ac t or checks (2) , t he Con t r ac t or Mus t a l sc t ose , De l ow or in an a l l oc t t menT t o th i s documen t , a l l r equ i s i t e i n f or rna r i on c i s se t f a rm i n ma t pa r ag r aph (21 . x 11- The Con t r ac t o r ven i r es t ha t (a) t he CorTr r ac t or has sea r c r t ec any and a l l r ecoroS o f t he con t r ac t or ana any and a l l p rodae®sso r en t i t i es for r ecords o f i nves t Men t s or pro f i t s r rorn s l ave ry - t he s l ave i nc t a y. or s i aveno l de r i nsu r ance po l i c i es , one (a) Con t r ac t or has f ound no r ecords o f I nves t menTs or pro f i t s f rom s l ave ry. t he s l ave i ndus t ry , o r s l ovcho l de r i nsur ance pouc l e i and no r ecords o f names o f any s l aves pr s l ayeno l de r s . 2. The Con t r ac t or ver i f i es t ha t . as a resu l t o f conduc t i ng t he sea r cn i n s t ep (11 (a) above . me con t r ac t or nos f auna r ecords r e i anng To i nvesr r r i en t s or pro t i n f rom s l ave ry. ThC+ s l ave i ndus t ry . or s l aveho l ae r i nsur ance po l i c i es and l o r t he names o f any s t aves or s i oveno l ae r s_ The Con t r ac t or ~er j f i es ThoT i ne f o l l ow i ng Cor t sT i t u t es fu l l d i sc l osur e o f a l l sucn r ecords . Acknow l edgmen t : L i v i ng Wage Ord i nance CONTRACTOR ACKNOWLEDGES AND AGREES THAT IF THIS ADDENDUM 15 BE I NG SUBM I TTED IN CONNECT I ON W I TH A PR I OR AGREEMENT. A MOD I F I CAT I ON TO A PR I OR AGREEMENT. OR W I TH A NEW AGREEMENT , THE FOLLOW I NG LI VI NG WAGE PROV I S I ONS SHALL BECOME PART OF SUCH MOD I F I CAT I ON OR AGREEMENT AND 5uPER5EDE OR REPLACE- ANT L I VI NG WAGE PROV I S I ONS THAT MAY BE CONTA I NED IN SUCH MOD I F I CAT I ON OR AGREEMENT ' A, unde r Sec t i on 2-92-610 o f t he Mun i c i pa l Code o f Ch i cago t he bQSe wage app l i es f or adna i n ca t egor i es o f wor ke r s emp l oyed i n Tne pe r f o r mance o f C i t y con t r ac t s . spec i f i ca l l y non -C i t y e r r t p l oyec l secur i t y gua rds pa r k i ng o t Tendanr s , C l ay l abore rs , home ana hea l t h ca r e wor ke r s . cash i e rs , e l eva t or ope r a t or s , cus t od i a l wor ke rs , and C l e r i ca l wor ke r s ( Cove r ed EMP l oyees - ) , Accord i ng l y , pur suan t t o 5ec t l on 2-92-b 10 ana r egu l a t i ons prornu l ga t ea . . unde r n I) i f me Con t r ac t or nos 25 or mo r e t i l l - tune emp l oyees. anc 2) I f a t any r i me dur i ng t he pe r f o rmance o f I l l s' con t r ac t t he Con t r ac t or and / o r any suoconva r t or Or any o t he r en t i t y Tha t pe r f orms any por t i on o f The canTr ac t ea wo r k . ( co l l ec t i ve l y " Pe r f a r rn i ng f a rT i es " j uses 25 or mo r e f un- t i me secur i t y guorc l s , or any numoe r o f o t he r f u t h t l me Cove r ed emp l oyees . t hen 31 M r Con t r ac t o r mus t pay i ts Cove r ed Emp l oyees ana musk assur e Tha t a l l o t he r Pe r f orm i ng Pa r r i es pay t ne i r Cove r ed Emp l oyees , no t Less Tnan I ne m i n i mum -Rose wage " as c i e t e rmcnea i n occo r agnce w i l n ?n i s Prov i s i on f or au Wo r k pe r f o r med pur suan t t o t he con t r ac t , Page I o f 2
  5. 5. ADDENDUM TO D ISCLOSURE AFF IDAVIT B_ The Con t r ac t o r s oo i rga t i on t o pay. anC To a= r e pcaymr n t o f . t he Base wage w l u beg i n a t any T i me aunng `he conTr aCT Te rm when The cond i t i ons se t f or t h i n A . I and A 2 above a r e me t . ana w i l l con t i nue t he r ea f t e r unf i t t he end o f The con t r ac t C Pr i or To Janua r y 1 . 2003 . t he Base wage is $7 60 pe r noun. beg i nn i ng Janua r y I . 2003. t he Base Wage is $4 05 pe r hou r . As o f Ju l y 1 . 2003 , and each Ju l y 1 i h®r ea f t e r , t he Base wage w i l l be aa l us t ecJ , us i ng The mos t r ecen t f ede r a l Pove r t y gu l e l e l i nes f or a f amuy o f f our as pub l i shed annua l l y by t he U .S . Depa r t men t o f Hea l t h 4nC r i uman Se rv i ces , ro cons t i t u t e The f o l l ow i ng : The pove r t y gu i de l i nes f or a fgrn i t y o f f our d l v i 0ed by 2000 h f l urs or t he cur r en t base wage . wn i c r t eve r i s h i ghe r . AT a l l T i mes dur i ng The t e rm o f Th i s connec t . con t r ac t or end an o t he r Pe r f orm i ng Pa r r i es mus t pay The Base wage ( as od l us r eq i n acco r agnce w i t h t he above ) _ I f t he paymen t o f pr eva i l i ng wages is r equ i r ed for Wo r k or se r v i ces none unde r th i s con t r ac t , ana t he pr eva i ung wages f or Cove r ed Emp l oyees o r e h i ghe r t han t he Base wage t hen The Con t r ac t o r ana a l l o t he r Pe r f orm i ng PQF f e5 mus t pay t he pr eva i l i ng wage r a t es . D The Con t r ac t or mus t I nc l ude prov i s i ons i n au subcon t r ac t s r equong i ts suDcon i r ac t or s t o pcy t he Base wage To Cove r ea Emp l oyees The COnTr aCTo r ag r ees t o prov i de me C i t y w i n c l ocumen t o t ron accep t c l b t e t o t he Ch l e r Procu r emen t O f f i ce r demons t r a t i ng t ha t a l l Cove r ed Emp l oyees . whe t he r emp l ayeq by t he Con t r ac t or or by a subc r anTr ac t OC have been pa i d The Base wage - upon t he C i t y ' s r eques t f or such documen t a t i on . Tne CI TY may I ndependen t l y aug i t v i e con t r ac t or and / o r subcon t rOC I OrS To ve r i f y comp l i ance ne r ewr t h . Fa i l ure t o comp l y w i Tn t he r equ l r e rhenTS o f Th i s Sec r on w i l l De an even t o f c l e fqu l t unde r Tnt5 con t r ac t . and f ur t he r . f a i l ure To comp l y may resu l t i n rne i , go i l r t y f or any awa r d o f a C i t y con t r ac t or suc ) conwac t for up To Thr ee (3) yea rs , E. toot - for -Prof i t Corpor a t i ons: i f Tne Con t r ac t or is a corpor a t i on na - i ng Fede r a l t ax - exemp t s t a tus unae r SecT l on 501 ICJ (3) o f Tne Int erna l Revenue Coae ana is r acQSn , zod ynqt i r r I r fnom not - for -prof l i I c l w . t hen The pravh , ons o f Sec t i on A througt ' r D above co no t app l y . Unde r pena l t y o f pequ r y. I ce r t i f y t ha t 1 qn ' t gwhor r zec l t o execu t e Th i s Aaaenaum To D i sc l osur e Af f i Gavr t on neha i f o f Tne Con t r ac t or , Tr1o1 1 have pe r sona l know l edge o f t he ce r t i f i ca t i ons be i ng made i n i t and Sha t t hey a r e comp l e t e ono True (Pr int or t ype n By . Da t e : Y. .. 9 - 0 - 5 I wVn I Or a ) Pr i nt or Type n Ti t l e o f s l gno i cownry or cwn t y Or 5mo0 - l . _ I i nC i s V - S I O I i Or ,_ ~c~no . . l ocgeo wx7d mm en I gd t i r , l J~ 61 7. 003 ~cu r a neggoa . mae oom an ma i d a - r oomony ~ [ 2L1 r~ I . - aQ IiS oewome Gor Inral - . Sen i ~~ J i r -~ Pr eS i dQ . l n1~ or i r tml Ne rdy P, . oK comnnsw a " aw Page ? ,
  6. 6. Spec i f i ca t i on No , : C92S990002 Pre -Quah f t ca t i oa Progr am Da t e Approved by Law : June 25 , 2003 APP I DAV I T The unde rs i gned. cer t i f i es tha t the Ecoaom i c D i sc l os= St a t emc ru And Af f i dav i t wh i ch the Consu l t an t comp l e t ed and cxecu t ed , as descr i bed above , rema i n t rue ac i d accura t e i n a l l respec t s as i f the Af f i dav i t s ara a t t ached here to . Ve r i f i mr i on Unde r penWTy o f pe r j my , I ce r t i f y t ha t 1 am t he Sen i o r V i ce P r es i den t (T i t l e ) , o f Pa t r i ek Eng i nee r i ng , I nc . and. tha t I am author i zed by t he Consu l t an t to execu t e th i s a f f i dav i t i n us beha l f , tha t have persona l know l z f e o f the ce tE i f i ca t i ons made i n th i s a f f i dav i t and tha t there have been no changes and tha t the same a t e t rue. Ted W . Lachus Na rue (Type or Pr i nt ) Sta te o f-T l l i rao i s Coun t y o f Subsc r i bed and sworn to me be fore th i s , 3=day o f S ' l eT-1- eam f - ' 20 03 Pub l i c S i My Comm i ss i on Exp i res 21 I L161, OFF I M SEAL MAR t AM OLAE i A NOTARY P l " - STATEOF wags MY cok i i am : o9-am
  7. 7. Spec i f i ca t i on No . : C925-99-0025 Pre-Qua l i f i ca t i on Progr am Da t e Execu t ed : Ju l y 18, 2000 AFF I DAV I T The unde rs i gned cer t i f i es tha t the D i sc l osure Af f i dav i t and / or Af f i dav i t (s) (co l l ec t i ve l y , the "Af f i dav i t s " ) wh i ch the Consu l t ant comp l e t ed and execut ed , as descr i bed above , rema i n t rue and accura t e i n a l l respec t s as i f the Af f i dav i t s are a t t ached here to . Ver i f i ca t i on Unde r pena l o f per j ury , I cer t i fy tha t I am the ~2~ (Ti t l e) , o f 4~ - _L (Pa t r i ck Eng i neer i ng , Inc . ) , and tha t I am author i zed by the Consu l t ant to execut e th i s a f f i dav i t i n i ts beha l f , tha t have persona l know l edge o f the cer t i f i ca t i ons made i n th i s a f f i dav i t and tha t there have been no changes and tha t the same are t rue . ~_ J- P. L04.. 4- ) S i gna ture o f Owne r or Authors Of f i cer _ C2 P ..L' ~z I~~ Name (Type o f Pr i nt ) St a t e o f . r 11 ; »o ; s Coun t y o f e Subscr i bed and swo to me be fore th i s a± ! dayo f be c . , 200- .4 I My Comm i ss i on Exp i res / 0 03
  8. 8. UE i / 24 / 2UU3 12 : 58 FAX 312 220 0722 R 002 FOR CITY USE AFF IDAVIT NO CITY OF CH I CAGO ECONOM I C D I SCLOSURE sTATEMENY AND AFF IDAVIT Pursuant to Chapter 2-154 of the Mun i c i pa l Code of Ch i cago ( the ' Mun i c i pa l Code ' s or , i f appl i cabl e , under § 8.5 of the l i rmois Mun i c ipa l Purphas i ng Ac t 65 ILCS 518-10-8.5 ( the ' Purchas i ng Act ` ) , the fol lowing Informat ion is requ i red to be d i sc l osed be fore any Ci ty agency. depar tment a Ci ty Counc i l acf ron. P l ease tuf ty comp l e t e each statement , wi th al l informat ion cur rent as of the da t e this Econom i c D i sc losure St a t ement and Af f idavi t ( " EDT) is s i gned . Every quest i on mus t be answered. I f a quest i on is not appl i cabl e , answer wi th ' N . A' An Incomp l e t e ED$ wi l l be re turned and any Ci ty ac t i on wi l l be inter rupted . P l ease pr int or type al l responses c l ear l y and legibly . Add addi t iona l pages i f needed , be i ng careful to ident i fy the por t ion of the EDS to wh i ch each addi t iona l page refers- WHO MUST SUBM I T AN EDS : 1. App l i cants - Any indi v idua l or ent i ty ( the "App l i cane) mak i ng an appl i cat ion to the Ci ty of Ch i cago ( the 'Ci ty' ) for act ion requi r ing Ci ty Counc i l or other tat ty agency approva l mas t f i le this EDS. For examp l e , vendors seek i ng Ci ty cont rac ts and i nd i v i dua l s or ent i t i es app l y i ng for concess i ons , l oans or grant s are "App l i cants . " 2 Ent i t i es ho l d i ng an interest i n the App l i cant Genera l l y , whenever an ownersh i p Interest in the App l i cant (such as shares of stDcrof the App l i cant or a l imi ted par tnersh ip interest in the Appl i cant , for examp l e) Is he l d or owned by a l ega l ent i ty (such as a corporat ion or par tnersh ip, for examp l e) rather than an individua l , each such l ega l ent i ty mus t a l so f i le an EDS on i ts own beha l f , and any parent of that l ega l ent i ty mus t do so, except as prov i ded be low, unt i l indi v idua l owners are d i sused . P i e= see Chapt er 2-154 of the Mun i c i pa l Code for fur ther deta i l s tegard' rng the nature and extent of d i sc losure requi red- Under the Mun i c i pa l Code , iP the App l i cant is a corporat ion whose shares are regi stered on a nat iona l secur i t i es exchange pursuant to the Secur i t i es Exchange Ac t of 1934, on l y l ega l ent i t ies that own 10 96 or more of the Appf i eanfs stock mus t f i le EDSs an the i r own beha tE However , under the Purchas i ng Ad , l ega l ent i t i es ho l d i ng 7 .596 or more of a vendor App l i cant mus t f i le EDSs . ACKNOWLEDGMENT OF POSS I BLE CRED I T AND OTHER CHECKS : By comp l et i ng and f i l ing this EDS , the Unders i gned i eknow i edges and agrees , on beha l f of i tsel f a i d the indi v idua l s named in thi s WS , that the Ci ty rmy inves l igate the cred i twor th iness of some or an of the indi v idua l s named in this EDS. CERTI FYI NG TH IS EDS: Execute the cer t i f icat ion an the da t e of the ini t ial submi ss i on of this EDS_ You may be asked to re-cer t i fy thi s EDS an the l ast page as of the da t e of subm i ss i on of any re l ated ord i nance to the Ci ty Counc i l , or as of the da t e of the c l os i ng of your t ransac t i on . PUBLI C D I SCLOSURE: I t is the Cqs pol i cy to make this dacument ava i l abl e to the pub l i c on i ts k i sme t si te and/or upon , request GENERAL I NFORMAT I ON Da t e this EDS comp l e t ed: _ ATa r i 1 4 , _ 2003 A Who is submi t t i ng th i s EDS? Tha t par ty wi l l be the ' Unders i gned" throughout this EDS . Ig) Check here If you are f i l ing as 'App l i cant ' Exac t l ega l name: Pa t r i ck Eng i nee r i ng I nc . [ ] Check here i f you are f i l ing as an "ent i ty ho l d i ng an interest in an App l i cant ' Exac t l ega l name : (Al so, p l ease ident i fy App l i cant in wh i ch this ent ty ho l ds an Interest B. Bus i ness address: - 5 5 Eas t Mon r oe . Su i t e 3 A 5 0 Ch i cago , I L 60603 C. Te l ephone ,3 12 - 201 - 7900 Fax : - 3 - 12 - 220 - 07 21 - Ermai t_, D. Name of contact person : r %K Ee _r r a r_ a E. I f a proauemen t Spec i f i cat ion k C 9 2 5 4 9 0 0 0 2 and Cont ract # _ - F. I f not a procurement 1 . Ci ty Agency request i ng EDS __ 2. , Ci ty act ion requested (e .g_ loan, grant , sa l e of proper ty) : 3. I f proper ty invol ved, f ist proper ty locat ion : G. Br i e f descr i pt i on of proj ect , ( i nc l ude pro j ec t numbe r and l ocat i on i f app l i cab l e) : p r e rn , a 1 i f i ea t ; nn EDS 03 I M Fw Iedera lhr - funded and nom-4ederauy f Wed rmbas. Page 1 o f 13
  9. 9. SECT I ON ONE : D I SCLOSURE OF OWNERSH I P I NTERESTS NATURE OF ENTI TY Indi cate whe ther the Unders i gned is an individua l or l ega l ent i ty : [ ] Indi v idua l [ ] Limi ted Liabi l i ty Company [y j Bus i ness corporat ion ( ] Joint venture [ ] So l e propr i etorship [ ] Not - for -prof i t corporat ion [Is the not - for -prof i t corporat ion a l so a 501(c) (3)? [ ] Yes [ ] No . [ ] Genera l par tnersh ip [ ] Other ent i ty (p l ease spec i fy) [ ] Limi ted par tnersh ip 2. State of incorporat ion or organi zat ion, if appl i cabl e : I l l i no i s 3. For l ega l ent i t ies not organ i zed in the State of I l l inois : Is the organ i zat ion author i zed to do bus i ness in the State of I l l inois as a fore ign ent i ty? [ ]Yes [ ] No D( ]N IA B. ORGAN I ZAT I ON I NFORMAT I ON 1. IF THE UNDERS I GNED IS A CORPORAT I ON : a. List be l ow the names and t i t les of al l execut i ve of f i cers and al l di rectors of the corporat ion . For not - for-prof i t corporat ions, a l so l ist be l ow any execut i ve di rector of the corporat ion, and indi cate al l members , i f any , who are l ega l ent i t ies. I f there are no members , wr i te 'no members." Name Tide Dan i e l P . D i e t z l e r P r es i den t Je f f r ey C . Schuh Sr . V i ce Pr es i den t Ma r k D . Rauckho r s t Sr . V i ce Pr es i den t Ted W . Lachu - Sr . V i ce Pr es i den t b. For corporat ions whose shares are regi stered on a nat iona l secur i t i es exchange pursuant to the Secur i t i es Exchange Ac t of 1934, p l ease prov ide the fo l lowing informat ion concern i ng shareho l ders who own shares equa l to or in excess of 10 % (or 7 .5 % , as appl i cabl e) of the corporat ion's outstand i ng shares . Not e: it may be necessary for some shareho l ders to comp l e te an EDS as an "Ent i ty ho l d i ng an interest in the App l i cant. " Name Bus i ness Address Percent age Interest N/A c. For corporat ions that are not reg i stered on a nat iona l secur i t i es exchange pursuant to the Secur i t i es Exchange Ac t of 1934, l ist be l ow the name , bus i ness address and percentage of ownersh i p interest of each shareho l der . Not e: i t may be necessary for some shareho l ders to comp l e t e an EDS as an "Ent i ty ho ld ing an interest in the App l i cant . " Name Bus iness Address Percentage Interest Dan i e l P. D i et z l er 55 Eas t Mon r oe , Su i t e 3450 100% EDS 03103 For federa l l y- funded and non- federa l l y funded mat ters Page 2 o f 13
  10. 10. 2. IF THE UNDERS I GNED IS A PARTNERSH I P : For genera l or l imi ted par tnersh i ps : l ist be l ow the name , bus i ness address and percent age of ownersh i p interest of each par tner. For f imt ted par tnerships, indi cate whe ther each par tner is a genera l par tner or a l imi ted par tner . Not e: N may be necessary for some par tners to comp l e te an EDS as an "Ent i ty ho l d i ng an interest in the App l i cant . " Name Bus i ness Address Percentage Interest N/A 3. IF THE UNDERS I GNED IS A LIMITED LIABILITY COMPANY: a. List be l ow the name , bus i ness address and percentage of ownersh i p interest of each (i) membe r and (i i) manager . I f there are no managers , wr i te 'no managers , and indi cate how managed . Not e : it may be necessary for some members to comp l e te an EDS as an 'Ent ry ho l d i ng an interest in the App l i cant . ' Name Bus i ness Address Percentage Interest N/ A b. List be l ow the names and t i t les of al l of f icers, i f any . I f there are no of f icers, wr i te 'no of f i cers ' Name Ti t le N/A 4. IF THE UNDERS I GNED IS A LAND TRUST , BUS I NESS TRUST OR ESTATE : a. List be l ow the name of each indi v idua l or l ega l ent i ty ho ld ing l ega l bi le to the proper ty that is the sub j ect of the t rust. Name Business Address N/A b. List be l ow the name , bus i ness address and percent age of benef i c i a l interest of each benef i c i ary on whose beha l f t i t le is he l d. Not e. i t may be necessary for some benef i c i ar i es to comp l e t e an EDS as an 'Ent i ty ho l d i ng an interest in the App l i cant . " Name Bus iness Address Percentage Interest N/A EDS 03103 For federa l y- runded and non4edera l l y funded mat ters . Page 3 o f 13
  11. 11. SECT I ON TWO : BUS I NESS RELAT I ONSH I PS W I TH CITY ELECTED OFF ICIALS A. DEF IN ITIONS AND D I SCLOSURE REQU I REMENT 1. Pursuant to an ord i nance approved by the Ci ty Counc i l on December 2, 1998, the Unders i gned mus t indi cate whe ther i t had a 'bus i ness re l at ionship" wi th a Ci ty e l ected of f icial in the 12 months be fore the da te this EDS is s i gned. 2. A ' bus i ness re l at ionsh ip' means any ' cont ractua l or other pr i vate bus i ness dea l ing' of an of f icial , or his or her spouse , or of any ent i ty in wh i ch an of f icial or his or her spouse has a ' f inanc i a l interest , " wi th a person or ent i ty wh i ch ent i t les an of f icial to compensa t i on or payment in the amoun t of $2,500 or more in a ca l endar year ; but a " f inanc ia l interest " does not inc lude: ( i ) any ownersh i p through purchase at fai r marke t va l ue or inher i tance of l ess than 1% of the shares of a corporat ion, or any corporate subs idi ary, parent or af f i l iate thereof , regard l ess of the va l ue of or d i v i dends on such shares , if such shares are regi stered on a secur i t i es exchange pursuant to the Secur i t i es Exchange Ac t of 1934 , as amended , a the author i zed compensa t i on pa id to an of f icial or emp l oyee for his of f ice or emp l oyment ; @i ) any econom i c benef i t prov i ded equa l l y to al l res idents of the Ci ty; ( iv) a t i me or demand depos i t in a f inanc i a l inst i tut ion ; or (v) an endowmen t or i nsurance po l i cy or annu i ty cont ract purchased f rom an i nsurance company. A "cont ractua l or other pr i vate bus i ness dea l ing" does not inc lude any emp l oyment re l at ionship of an of f icial 's spouse wi th an ent i ty when such spouse has no di scret ion concern i ng or input re l at ing to the re l at ionship be tween that ent i ty and the Ci ty. B. CERTI F I CATI ON 1. Has the Unders i gned had a "bus i ness re l at ionship" wi th any Ci ty e l ected of f icials in the 12 months before the da te this EDS is s i gned? [ ] Yes [XI No I f yes , p l ease ident i fy be l ow the name(s) of such Ci ty e l ected of f icial (s) and descr i be such re l at ionship(s) : " STOP I f you are f i l ing on beha l f of an "Ent i ty ho l d i ng an interest in the App l i cant , " go to Sec t i on Seven (Not i ce and Acknow l edgmen t Regard i ng Ci ty Government a l Eth i cs and Campa i gn F i nance Ord i nances) , page 12. The fo l l ow i ng sec t i ons Three through Si x are to be comp l e t ed on l y by the App l i cant in the App l i cant ' s EDS : EDS 03103 For teder*- rurded and nw~Ay l anded moose. Page 4 of 13
  12. 12. 06 / 24 / 2003 12 : 58 FAX 312 220 0722 19003 SECT I ON THREE : D I SCLOSURE OF RETAI NED PART I ES A. DEF IN ITIONS AND D I SCLOSURE REQU I REMENTS 1. Pursuant m Execut i ve Order 97-1, every Ci ty cont ract , l ease , and al l mat ters requi r ing Ci ty approva l mus t be accompan i ed by a sta tement di sc los ing cer ta in informat ion about at torneys, lobby i sts, accountants , consu l tants , subcont ractors , and any other person whom the App l i cant has reta ined or expec ts to reta in in connect i on wi th the mat ter in connect i on wi th wh i ch this EDS is submi t ted. In par t i cul ar , the App l i cant mus t d i sc lose the name of each such person, h' isfher bus i ness address , the na ture of the re l at ionship, and the amoun t of the fees pa id or est i mated to be pa i d . The App l i cant is not requi red to d i sc lose emp l oyees who are pa i d so l e l y through the App l i cants regu l ar payrol l . "Lobby i st " means any person (7 who , for compensa t i on or on beha l f of any person other than himse l f , under t akes to inf luence any l egisl at ive or admini st rat i ve act ion, or ( t1 any par t of whose duty as an emp l oyee of another inc ludes under tak i ng to Inf luence any l egisl at ive or admin i st rat i ve act ion . 2_ i f the App l i cant is uncer ta in whe ther a d i sc losure is requ i red under this Sect ion, the App l i cant mus t e i ther ask the Ci ty whe ther d i sc losure is requi red or make the d i sc losure . B. CERTI F I CATI ON Each and every at torney, lobbyist , accountant , consul tant , subcont ractor , or other person reta ined or ant i c ipated to be reta ined di rect ly by the App l i cant wi th respect to or in connec t i on wi th the proj ect or t ransact ion that Is the sub j ect of this EDS is l isted be l ow [beg in l ist here , add shee ts as necessary) , Name Us l ness Re l at ionsh ip to Appkan i Fees Address (at torney, lobby i st etc.; ( indi cate whe ther pa id or eAnra l ed) reta ined or anfdpa t ed to be reta ined) I )a CHECK HERE IF NO SUCH PERSONS HAVE BEEN RETAI NED D I RECTLY BY THE APPL I CANT O i l ARE ANT I CI PATED TO BE RETAI NED D I RECTLY BY THE APPL I CANT . SECT I ON FOUR : CERTI F I CATI ONS BY APPL I CANT I. CERTI F ICATION OF COMPL I ANCE For purposes of the cer t i f icat ions in A, B, and C be low, the t erm "af f i l iate" means any ent i ty that , di rect ly or indi rect l y. cont rol s the App l i cant , is cont rol l ed by the Appl i cant , or is, wi th the Appl i cant , under common cont rol of another indi v idua l or ent i ty . Indic ia of cont rol inc lude , wi thout l imi tat ion : inter lock ing managemen t or ownersh i p; ident i ty of interests among fami l y members , shared faci l i t ies and equ i pment ; common use of emp l oyees ; or organ i zat ion of a bus i ness ent i ty fo l lowing the inel igibi l i ty of a bus i ness ent i ty to do bus i ness wi th the federa l government or a state or loca l government , inc luding the Ci ty, us i ng substant i a l l y the same management , ownersh i p , or pr inc ipa l s as the ine l igible ent i ty. A. The App l i cant is not de l i nquent in the payment of any tax admi n i stered by the I l l inois Depar tment of Revenue , nor are the App l i cant or i ts af f i l iates de l i nquent in pay i ng any f ine, fee , tax or other charge owed to the Ci ty. Th i s inc ludes al t wa t er charges , sewer charges , l i cense fees, park ing t ickets, proper ty taxes or sa l es taxes. I f there are any such de l inquenc i es , note them be l ow: No- i f the let ters "NA, " the word "None , " or no response appears on the l ines above , it wi l l be conc lus i ve l y presumed that the App l i cant cer t i f ied to the above sta tements . EDS 03103 For federa l l y- funded end i ron- federa l l y funded ma f te i s. Page 5 o f 13
  13. 13. B. The App l i cant and i ts af f i l iates have not , in the past f ive years , been found in violat ion of any Ci ty, state or federa l env i ronmenta l l aw or regul at ion . I f there have been any such violat ions, note them be l ow: None I f the let ters *NA,* the word 'None , ' or no response appears on the f ines above , it w i g be conc lus i ve l y presumed that the App l i cant cer t i f i ed to the above statements . C. The App l i cant and i ts af f i l iates wi l l not use , nor permi t the i r subcont ractors to use , any faci l i ty on the U .S. EPA' s List of Viol at ing Fac i l i t ies in connec t i on wi th the proj ect or t ransact ion for the durat ion of t i me that such faci l i ty rema i ns on the l ist. D. The App l i cant wi l l obta in f rom any cont ractors/subcont ractors hi red or to be hi red in connec t i on wi th the Ci ty cont ract , work , bus i ness , or t ransact ion that is the sub j ect of this EDS cer t i f i cat ions equa l in form and substance to those in Sect i on Four , 1,A-C above and wi l l not , wi thout the pr ior wr i t ten consent of the Ci ty, use any such subcont ractor that does not prov ide the cer t i f icat ion or that the App l i cant has reason to be l i eve has not prov i ded or cannot prov i de t ruthful cer t i f icat ions . I f the App l i cant is unab l e to so cer t i fy, prov i de an exp l anat ion : I f the let ters 'NA, ' the word 'None , " or no response appears on the l ines above , it wi l l be conc lus i ve l y presumed that the App l i cant cer t i f ied to the above statements . II . CH I LD SUPPO RT OBLI GATI ONS- CERTI F I CATI ON REGARD I NG COURT-ORDERED CH I LD SUPPORT COMPL I ANCE For purposes of this par t , 'Substant i a l Owner " means any person who , d i recdy or indi rect ly, owns or ho lds a 10 % or more . interest in the App l i cant . Not e: Th i s may inc lude indi v idua l s d i sc l osed in Par t One (D i sc losure of Ownersh i p Interests) , and indi v idua l s d i sc losed in an EDS f i led by an "Ent i ty ho l d i ng an interest in the App l i cant. " I f the Appl i cant 's response be l ow is #1 or #2, then al l of the App l i cants Substant i a l Owners mus t rema i n in comp l i ance wi th any such chi ld suppor t obl igat ions unf i l the t ransact ion is comp l e t ed . Fa i lure of the App l i cants Substant i a l Owners to rema i n in comp l i ance wi th the i r chi ld suppor t obl igat ions in the manner se t for th in e i ther #1 or #2 const i tutes an event of defau l t . Moreover , fai lure of the App l i cant to comp l y wi th the prov i s ions of § 2-92-415(e) of the Mun i c i pa l Code a l so const i tutes an event of defau l t . Check one: _X_ 1 . No Substant i a l Owner has been dec l ared in ar rearage on any chi ld suppor t obl igat ions by the Ci rcui t Cour t of Cook Count y or by another I l l inois cour t of compe t ent jur isdict ion. 2. The Ci rcui t Cour t of Cook Count y or another I l l inois cour t of compe t ent jur isdi ct ion has i ssued an order dec l ar ing one or more Substant i a l Owners in ar rearage on chi ld suppor t obl igat ions . Al l such Substant i a l Owners , however , have entered into cour t - approved agreement s for the payment of al l such chi ld suppor t owed , and al l such Substant i a l Owners are in comp l i ance wi th such agreement s. - 3. The Ci rcui t Cour t of Cook Count y or another I l l inois cour t of compe t ent jur isdi ct ion has i ssued an order dec l ar ing one or more Substant i a l Owners in ar rearage on chi ld suppor t obl igat ions and (a) at l east one such Substant i a l Owne r has not entered into a cour t -approved agreement for the payment of al l such chi ld suppor t owed ; or (b) at l east one such Substant i a l Owne r is not in comp l i ance wi th a cour t -approved agreement for the payment of al l such chi ld suppor t owed ; or both (a) and (b) . 4 . There are no Substant i a l Owners. EDS 03103 For federa l l y- funded and non- federa l l y funded mat ters . Page 6 of 13
  14. 14. III . FURTHER CERT I F I CAT I ONS A. The App l i cant and , if the App l i cant is a l ega l ent i ty, i ts pr inc ipa l s (of f icers, di rectors, par tners, members , managers , execut i ve di rector ) : 1. are not present l y debar red, suspended , proposed for debarment , dec l ared ine l igible or voluntar i ly exc l uded f rom any t ransact ions by any federa l , state or loca l uni t of government ; 2. have not wi thin a f i ve-year per iod preced i ng the da te hereof been conv i cted of a cr imina l of fense , ad j udged gui l ty, or had a civi l j udgment rendered aga inst them in connec t i on wi th: obta ining, at tempt ing to obta in, or per formi ng a pub l i c ( federa l , state or local ) t ransact ion or cont ract under a publ i c t ransact ion; a violat ion of federa l or state ant i t rust statutes; f raud ; embezz l ement ; thef t ; forgery; br ibery ; falsi f icat ion or dest ruct ion of records ; mak i ng fa l se statements ; or rece i v ing sto l en proper ty ; 3. are not present l y indi cted for or otherwi se cr imina l l y or civi l ly charged by a govemment a l ent i ty ( federa l , state or local ) wi th comm i ss i on of any of the of fenses enumera t ed in c l ause (b) above; 4.. have not wi thin a f i ve-year per iod preced i ng the da te of this EDS had one or more pub l i c t ransact ions ( federa l , state or loca l ) termi nated for cause or defaul t ; and 5. have not , wi thin a f i ve-year per iod preced i ng the da te hereof , been conv i cted, ad j udged gui l ty, or found l i abl e in a civi l proceed i ng , in any cr imina l or civi l act ion inst i tuted by the Ci ty or by the federa l government , any state, or any other uni t of loca l government . B. The cer t i f i cat ions in this subpar t B concern : " the App l i cant ; " any par ty par t i c ipat ing in the per formance of the proj ect or t ransact ion that is the subj ect of this EDS ( ' an App l i cab l e Par ty" ) ; " any 'Af f i l i ated Ent i ty" (mean i ng an ent i ty that , di rect ly or indi rect ly: cont rol s the Appl i cant , is cont rol l ed by the Appl i cant , or is, wi th the Appl i cant , under common cont rol of another indi v idua l or ent i ty . Indic ia of cont rol inc lude, wi thout l imi tat ion : inter lock ing managemen t or ownersh i p; ident i ty of interests among fami l y members , shared faci l i t ies and equ i pment ; common use of emp l oyees; or organ i zat ion of a bus i ness ent i ty fol lowing the inel igibi l i ty of a bus i ness ent i ty to do bus i ness wi th federa l or state or loca l government , inc luding the Ci ty, us ing substant i a l l y . the same management , ownersh i p, or pr inc ipa l s as the inel igible ent i ty) ; wi th respec t to App l i cab l e Par t i es, the t erm Af f i l iated Ent i ty means an ent i ty that di rect ly or indi rect l y cont rol s the App l i cab l e Par ty, is cont rol l ed by it, or , wi th the App l i cab l e Par ty, is under common cont rol of another indi v idua l or ent i ty; " any respons i b l e of f icial of the Appl i cant , any App l i cab l e Par ty or any Af f i l iated Ent i ty; any other of f icial , agent or emp l oyee of the Appl i cant , any App l i cab l e Par ty or any Af f i l iated Ent i ty, act ing pursuant to the di rect ion or author i zat ion of a respons ib l e of f icial of the Appl i cant , any App l i cab l e Par ty or any Af f i l iated Ent i ty . Ne i ther the Appl i cant , nor any App l i cab l e Par ty, nor any Af f i l iated Ent i ty of e i ther the App l i cant or any App l i cab l e Par ty have , dur ing the f ive years before the da t e this EDS is s igned, or , wi th respect to an App l i cab l e Par ty, an Af f i l iated Ent i ty, or an Af f i l iated Ent i ty of an App l i cab l e Par ty dur i ng the f ive years before the da te of such App l i cab l e Par ty 's or Af f i l iated Ent i ty's cont ract or engagement in connect i on wi th the pro j ect or t ransact ion that is the sub j ect of this EDS : 1. t i r ibed or a t tempted to br ibe, or been conv i cted or ad j udged gui l ty of br ibery or at tempt ing to br ibe, a pub l i c of f icer or emp l oyee of the Ci ty, the State of I l l inois, or any agency of the federa l government or of any state or loca l government in the Un i ted States of Amer i ca , in that of f icer 's or emp l oyee ' s of f icial capac i ty; 2. agreed or co l l uded wi th other b i dders or prospect i ve bidders, or been a par ty to any such agreement , or been conv i cted or ad j udged gui l ty of agreement or col lus ion among b i dders or prospect i ve bidders, in rest ra int of f reedom of compet i t ion by agreement to b id a f ixed pr i ce or otherw i se; or 3. made an admi ss i on of such conduc t descr i bed in (1) or (2) above that is a ma t ter of record, but have not been prosecuted for such conduc t ; or 4. v iol ated the prov i s ions of § 2-92-610 of the Mun i c i pa l Code (Li v i ng Wage Ord i nance) . C. The App l i cant understands and sha l l comp l y wi th (1) the app l i cab l e requ i rements of the Government a l Eth i cs Ord i nance of the Ci ty, Ti t le 2, Chapter 2-156 of the Mun i c ipa l Code ; and (2) al l the app l i cab l e prov i s ions of Chapter 2-56 of the Mun i c i pa l Code (Of f ice of the Inspector Genera l ) . EDS 03103 For federe l l y4unded end non- federa l l y funded mat ters . Page 7 o f 13
  15. 15. D. Ne i ther the App l i cant nor any emp l oyee , of f icial , agent or par tner of the App l i cant is bar red f rom cont ract ing wi th any uni t of state or loca l government as a resul t of engag i ng in or be i ng conv i cted of (1) bid- r igging in viol at ion of 720 a CS5133E-3, (2 , x - rotat ing in viol at ion of 720 ILCS 5133E-4 ; or (3) any s imi l ar of fense of any state or of the Un i ted States of Amer i ca that conta i ns the same e l ements as the of fense of bid- r igging or bid- rotat ing . E. I f the App l i cant is unab l e to cer t i fy to any of the above sta tements in this Par t III, the App l i cant mus t expl a in be l ow: I f the let ters 'NA, ' the word ' None , or no response appears on the l ines above , it wi l l be conc lus i ve l y presumed that the App l i cant cer t i f ied to the above sta tements. IV. CERT I F I CAT I O N ON STATUS AS F I NANCI AL INSTITUTION For purposes of this Par t IV, under § 2-32-455(b) of the Mun i c i pa l Code , the term "F inanc i a l Inst i tut ion' means a bank , sav i ngs and loan assoc i at ion, thri ft , credi t union, mor tgage banker , mor tgage broker , a t rust company , a sav i ngs bank , an i nvestment bank , a secur i t i es broker , a mun i c i pa l secur i t i es broker , a secur i t i es dea l er , a mun i c ipa l secur i t i es dea l er , a secur i t i es underwr i ter , a mun i c i pa l secur i t i es underwr i ter , an i nvestment trust , a venture capi ta l company , a bank holding company , a f inanc i a l serv i ces ho l d i ng company , or any l i censee under the Consumer Insta l lment Loan Act , the Sa l es F i nance Agency Act , or the Res ident i a l Mor tgage Li cens i ng Ac t . However , " f inanc i a l inst i tut ion" spec i f i ca l ly sha l l not inc lude any ent i ty whose predomi nant bus i ness is the prov id ing of tax defer red, de f i ned cont r ibut ion, pens i on p l ans to publ i c emp l oyees in accordance wi th Sect ion 403(b) and 457 of the Interna l Revenue Code . [Addi t iona l def ini t ions may be found in Sec t i on 2-32-455(b) of the Mun i c ipa l Code.] A. CERTI F I CATI ON The App l i cant cer t i f ies that the App l i cant [check one] _ is X is not a " f inanc i a l inst i tut ion' as def ined in Sec t i on 2-32-455 (b) of the Mun i c ipa l Code . B. I f the App l i cant IS a f inanc i a l inst i tut ion, then the App l i cant p l edges: " We are not and wi l l not become a predatory l ender as de f i ned in Chapt er 2-32 of the Mun i c ipa l Code of Ch i cago. We fur ther p l edge that none of our af f i l iates is, and none of them wi l l become , a preda tory l ender as de f i ned in Chapter 2-32 of the Mun i c i pa l Code. We understand that becom i ng a predatory l ender or becom i ng an af f i l iate of a predatory tender may resul t in the loss of the pr i v i l ege of do i ng bus i ness wi th the Ci ty. " I f the App l i cant is unab l e to make this p l edge because it or i ts af f i l iates (as de f i ned in § 2-32-455(b) of the Mun i c ipa l Code) are predatory l enders wi thin the mean i ng of Chapter 2-32, exp l a in here (at tach addi t iona l pages i f necessary) : I f the let ters 'NA, " the word 'None , ' or no response appears on the l ines above , i t wi l l be conc lus i ve l y presumed that the App l i cant cer t i f i ed to the above sta tements . V. CERTI F ICATION REGARD I NG I NTEREST IN CI TY BUS I NESS Any words or terms that are def ined in Chapt er 2-156 of the Mun i c i pa l Code have the same mean i ngs when used in this PART V. 1. In accordance wi th § 2-156-110 of the Mun i c i pa l Code : Does any of f icial or emp l oyee of the Ci ty of Ch i cago have a f inanc i a l interest in h i s or her own name or in the name of any other person in the cont ract , work , bus i ness , or t ransact ion that is the sub j ect of this EDS? Yes. X No . EDS 03M For federa l l y- funded and non4edera l l y funded mat ters. Page 8 o f 13
  16. 16. 2. Un l ess so ld pursuant to a process of compet i t i ve bidding, no Ci ty e l ected of f icial or emp l oyee sha l l have a f inanc i a l interest in h i s or her own name or in the name of any other person in the purchase of any proper ty that (i) be l ongs to the Ci ty, or (i i) is so ld for taxes or assessments , or (i i i) is so ld by vi r tue of l ega l process at the sui t of the Ci ty (col lect ively, "Ci ty Proper ty Sa l e" ) . Compensa t i on for proper ty taken pursuant to the Ci ty's emi nent doma i n power does not const i tute a f inanc ia l interest wi thin the mean i ng of this PART V. Does the cont ract , work , bus i ness , or t ransact ion in connec t i on wi th wh i ch this EDS is submi t ted invol ve a Ci ty Proper ty Sa l e? Yes. X No . I f you answered "yes" to quest i on one above , ident i fy the Ci ty of f icials or emp l oyees hav i ng such interest and the nature of such interest : Name Bus i ness Address 3. The App l i cant fur ther cer t i f ies that no prohibi ted f inanc i a l interest in the cont ract , work , bus i ness or t ransact ion that is the sub j ect of this EDS wi l l be acqu i red by any Ci ty of f icial or emp l oyee. VI . CERTI F ICATION REGARD I NG SLAVERY ERA BUS I NESS Sect i on 2-92-5135 of the Mun i c ipa l Code requi res that any ent i ty enter ing into a cont ract wi th the Ci ty mus t comp l e t e an af f idavi t ver i fy ing that the ent i ty has searched any and al l records of the ent i ty and any and al l predecessor ent i t ies for records of i nvestments or prof i ts f rom s l avery, the s l ave indust ry, or s l aveho l der i nsurance pol i c i es f rom the s l avery era ( inc luding i nsurance pol i c i es i ssued to s l aveho l ders that prov i ded coverage for damage to or injury or dea th of the i r s l aves) and mus t d i sc lose in the af f idavi t such records to the Ci ty. In addi t ion, § 2-92-585 requi res that the ent i ty d i sc l ose in the af f idavi t the names of any s l aves or s l aveho lders descr i bed in those records . Fa i lure to comp l y wi th § 2-92-585 makes the cont ract vo i dab l e on beha l f of the Ci ty . P l ease check e i ther (1) or (2) be l ow . I f the App l i cant checks (2) , the App l i cant mus t d i sc l ose be l ow or in an a t t achment to th i s EDS al l requ i s i te i nforma t i on as se t for th in tha t paragraph (2) . _x -1 . The App l i cant ver i f ies that (a) the App l i cant has searched any and al l records of the App l i cant and any and al l predecessor ent i t ies for records of i nvestments or prof i ts f rom s l avery, the s l ave indust ry, or s l aveho l der i nsurance pol i c i es, and (b) the App l i cant has found no records of i nvestments or prof i ts f rom s l avery, the s l ave indust ry, or s l aveho lder i nsurance pol i c i es and no records of names of any s l aves or s l aveho lders . _2. The App l i cant ver i f ies that , as a resul t of conduc t i ng the search in step (1) (a) above , the App l i cant has found records re l at ing to i nvestments or prof i ts f rom s l avery, the s l ave indust ry, or s l aveho l der i nsurance pol i c i es and/or the names of any s l aves or s l aveho lders . The App l i cant ver i f ies that the fol lowing const i tutes ful l d i sc losure of al l such records : SECT I ON F IVE : CERTI F ICATIONS FOR FEDERALLY- FUNDED MATTERS CHECK HERE [ ] AND SKIP THE CERTI F I CATI ONS IN SECT I ON F IVE, PARTS (I), (II), AND (III) IF THE CONTRACT , WORK , BUS I NESS OR TRANSACT I ON IN CONNECT I ON W I TH WH I CH TH IS EDS IS SUBM I TTED IS NOT FEDERALLY FUNDED . EDS 03103 For federa l l y funded and non- federa l l y funded ma t ters. Page 9 o f 13
  17. 17. I. CERTI F I CATI ON REGARD I NG LOBBYI NG A. List be l ow the names of al l persons regi stered under the federa l Lobby i ng D i sc losure Ac t of 1995 who have made lobby ing contacts on beha l f of the App l i cant wi th respect to the cont ract , work , bus iness , or t ransact ion that is or are the subj ect of this EDS: [Beg in l ist here , add shee ts as necessary) : ( I f no exp l ana t i on appears or beg i ns on the l ines above , or i f the l et ters " NA" or f f the word " None " appear , i t wi l l be conc l us i ve l y presumed that the App l i cant means tha t NO persons reg i stered under the Lobby i ng D i sc l osure Ac t of 1995 have made l obby i ng cont ac ts on beha l f of the App l i cant w i th respec t to the cont ract , work , bus i ness , or t ransact i on in connec t i on w i th wh i ch thi s EDS i s subm i t t ed.] B. The App l i cant has not spent and wi l l not expend any federa l appropr i ated funds to pay any person l isted in Paragraph (A) above for his or her lobby ing act ivi t ies or to pay any person to inf luence or at tempt to inf luence an of f icer or emp l oyee of any agency , as de f i ned by appl i cabl e federa l l aw, a membe r of Congress , an of f icer or emp l oyee of Congress , or as-, en l oyce of a membe r of Congress , in connect ion ; wi th the award of any federa l l y- funded cont ract , mak i ng any federa l l y- funded grant or loan, enter ing into any cooperat i ve agreement , or to extend, cont inue , renew, amend , or mod i fy federa l l y- funded cont ract , grant , ban , or cooperat i ve agreement C. The App l i cant wi l l submi t an upda ted Perbf i cat ion at the end of each ca l endar quar ter in wh i ch there occurs any event that mater i a l l y af fects the accuracy of the sta tements and informat ion set for th in Paragraphs (I .A.) and (I .B.) above . I f any funds other than federa l appropr i a t ed funds have been or wi l l be pa i d to any person for Inf l uenc i ng or a t t empt i ng to i nf l uence an of f i cer or emp l oyee of any agency , a membe r of Congress , an of f i cer or emp l oyee o f Congress , or an emp l oyee of a membe r of Congress in connec t i on w i th the federa l cont rac t ; grant , loan, or coopera t i ve agreement to wh i ch thi s EDS re l ates, the App l i cant mus t comp l e t e and subm i t St andard Form-LLL, "D i sc l osure Form to Repor t Lobby i ng , " in accordance w i th i ts i nst ruct i ons. The form may be obt a i ned on l i ne f rom the federa l Of f i ce of Managemen t and Budge t (OMB) web s i te a t ht tpJ / www . wh i t ehouse . aov/omb/ arants/sf i l l i n .adf , l i nked on the page ht tpJ / www . wh i t ehouse .oov /ombharants / arants f orm&h t ml . -D. The App l i cant cer t i f ies that e i ther (i) it is not an organ i zat ion descr i bed in sect ion 501(c) (4) of the Interna l Revenue Code of 1986; or (i i) it is an organ i zat ion descr i bed in sect ion 501(c) (4) of the Interna l Revenue Code of 1986 but has not engaged and wi l l not engage in "Lobby i ng Act ivi t ies" . E. The App l i cant must obta in cer t i f icat ions equa l in form and substance to paragraphs (I .A) through (I .D.) above f rom al l subcont ractors before it awards any subcont ract . The App l i cant mus t ma inta in al l such subcont ractors ' cer t i f icat ions for the durat ion of the cont ract and mus t make such cer t i f i cat ions prompt l y ava i l abl e to the Ci ty upon request II . C ERTI F ICATION REGARD I NG NONSEGREGATED FACILITIES A. The App l i cant does not and wi l l not ma inta in or prov i de for i ts emp l oyees any segrega ted faci l i t ies at any of i ts estab l i shments , and it does not and wi l l not permi t i ts emp l oyees to per form the i r serv i ces at any locat ion under i ts cont rol where segrega t ed faci l i t ies are ma i nta i ned. The App l i cant agrees that a breach of this cer t i f icat ion is a violat ion of the Equa l Oppor tun i ty c l ause in i ts cont ract wi th the Ci ty. "Segrega t ed faci l i t ies, " as used in this prov i s ion, means any wa i t ing rooms , work areas , rest rooms , washrooms , restaurants and other eat ing areas , t i me docks , locker rooms and other storage or dress i ng areas , park i ng lots, dr ink ing founta ins , recreat ion or enter ta i nment areas , t ranspor tat ion, and hous i ng prov i ded for emp l oyees , that are segrega t ed by expl ic i t di rect i ve or are in fact segrega ted on the bas i s of race , color , rel igion, sex, or nat iona l or igin because of habi t , loca l or emp l oyee custom, or otherw i se. However , separa ted or s ingl e-user rest rooms and necessary dress i ng or s l eep ing areas mus t be prov i ded to assure pr i vacy be tween the sexes . B. The App l i cant wi l l , before the award of subcont racts , obta in ident i ca l cer t i f icat ions f rom proposed subcont ractors under wh i ch the subcont ractor wi l l be sub j ect to the Equa l Oppor tun i ty c l ause . Cont rac ts and subcont racts exceed i ng $10,000, or hav i ng an aggrega t e va lue exceed i ng $10,000 in any 12-month per iod, are genera l l y sub j ect to the Equa l Oppor tun i ty c l ause. See 41 CFR Par t 60 for fur ther informat ion regard ing the Equa l Oppor tun i ty c l ause . The App l i cant mus t reta in the cer t i f icat ions requ i red by thi s paragraph F for the durat ion of the cont ract and mus t make such cer t i f icat ions prompt l y ava i l ab l e to the Ci ty upon request . EDS 03103 For f edemi y- funded and non- federa l l y funded mat ters. Page 10 of 13
  18. 18. C. The App l i cant wi l l forward the not i ce set for th be l ow to proposed subcont ractors: NOT I CE TO PROSPECT I VE SUBCONTRACTORS OF REQU I REMENTS FOR CERTI F I CATI ONS OF NONSEGREGATED FACILITIES Subcont rac tors mus t submi t to the Cont ractor a Cer t i f i cat ion of Nonsegrega t ed Faci l i t ies be fore the award of any subcont ract under wh i ch the subcont ractor wi l l be sub j ect to the federa l equa l oppor tun i ty c l ause. The subcont ractor may submi t such cer t i f icat ions e i ther for each subcont ract or for al l subcont racts dur ing a per iod (e .g., quar ter l y, semi annua l l y , or annua l l y) . III . CERTI F ICATION REGARD I NG EQUAL EMPLOYMENT OPPORTUN I TY Federa l regul at ions requ i re prospect i ve cont ractors (e .g., the App l i cant ) and proposed subcont ractors to submi t the fol lowing informat ion wi th the i r bids or in wr i t ing at the outse t of negot i at ions . A. Have you deve l oped and do you have on f i le af f i rmat ive act ion programs pursuant to appl i cabl e federa l regu l at ions? (See 41 CFR Par t 60-2.) [ A Yes [ ] No t3 . Have you par t i c ipated in any prev i ous cont racts or subcont racts sub j ect to the equa l oppor tuni ty c l ause? [ )dYes ( ] No C. Have you f i led wi th the Jo int Repor t i ng Commi t tee , the Di rector of the Of f i ce of Federa l Cont rac t Comp l i ance Programs , or the Equa l Emp l oyment Oppor tun i ty Comm i ss i on al l repor ts due under the appl i cabl e f i l ing requ i rements? [ ) I Yes [ ] No SECTI ON SIX : NOT I CE AND ACKNOWLEDGMENT REGARD I NG LIVING WAGE ORD I NANCE Sect ion 2-92-610 of the Mun i c i pa l Code( "L i v i ng Wage Ord i nance ' ) requi res that e l igible cont ractors (see A .1 . and 2 . be l ow) pay a spec i f i ed m i n i mum l iving wage ( 'Base Wage " ) to par t i cul ar categor i es of workers emp l oyed in connect i on wi th the per formance of cer ta in Ci ty cont racts . The Li v ing Wage Ord i nance app l i es to any wr i t ten agreement or subcont ract in connect i on wi th wh i ch ' the Ci ty is commi t t ed to expend or does expend funds ' and "wh i ch requi res in the per formance thereof the emp l oyment of those categor i es of workers. The ord i nance was amended to prov i de for a h igher Base Wage and regu l ar i ncreases to that wage ef fect i ve January 1, 2003. The amended ord i nance app l i es to agreement s predat ing the amendmen t as we l l as to new agreements . For purposes of this Sec t i on Six, the t erm 'Cont ractor " in paragraphs A through E be l ow means the App l i cant if the Li v ing Wage Ord i nance app l i es to a wr i t ten agreement in connect i on wi th wh i ch this EDS is submi t ted . [X] BY CHECK I NG TH IS BOX APPL I CANT ACKNOWLEDGES AND AGREES THAT IF TH IS EDS IS BE I NG SUBM I TTED IN CONNECT I ON W I TH A MOD I F I CATI ON TO AN EXISTING CONTRACT TO WH I CH THE LIVING WAGE ORD I NANCE APPLIES , THE FOLLOW I NG LIVING WAGE PROVI S I ONS W I LL BECOME PART OF SUCH MOD I F ICATION , SUPERSED I NG AND REPLACI NG ANY LIVING WAGE PROVI S I ONS THAT MAY BE CONTAI NED IN SUCH MOD I F I CAT I ON OR EXISTING CONTRACT . A. Under Sect i on 2-92-610 of the Mun i c ipa l Code the Base Wage app l i es for cer ta in categor i es of workers emp l oyed in the per formance of Ci ty cont racts, spec i f i ca l l y non-Ci ty emp l oyed secur i ty guards , park i ng at tendants, day l aborers, home and hea l th care workers , cashi ers, e l evator operators , custod i a l workers , and c ler ica l workers ( "Covered Emp l oyees ' ) . Accord ing l y , pursuant to Sect i on 2- 92-610 and regul at ions promu l ga ted under it: 1) If the cont ractor has 25 or more ful l - t ime emp l oyees , and 2) If at any t i me dur ing the per formance of the cont ract the cont ractor and/or any subcont ractor or any other ent i ty that per forms any por t ion of the cont rac ted work (col l ect ive ly ' Per formi ng Par t i es" ) uses 25 or more ful l - t ime secur i ty guards , or any number of other ful l - t ime Covered Emp l oyees , then 3) The cont ractor mus t pay i ts Covered Emp l oyees , and mus t assure that al l other Per formi ng Par t i es pay the i r Covered Emp l oyees , not l ess than the m i n i mum "Base Wage " as de termi ned in accordance wi th this prov i s ion for al l work per formed pursuant to the cont ract. EDS 03103 For federa l l y- funded and non- federa l l y funded mat ters. Page 11 o f 13
  19. 19. B. The cont ractor ' s obl igat ion to pay , and to assure payment of , the Base Wage wi l l beg i n a t any t i me dur ing the cont ract term when the cond i t ions set for th in A1 and A.2 above are met , and wi l l cont i nue thereaf ter unt i l the end of the cont rac t C. Pr ior to January 1, 2003, the Base Wage was $7.60 per hour , beg i nn i ng January 1, 2003, the Base Wage is $9 .05 per hour . As of Ju l y 1, 2003, and each Ju l y 1 thereaf ter , the Base Wage wi l l be adjusted, us ing the mos t recent federa l pover ty gu ide l ines for a fami l y of four as pub l i shed annua l l y by the U.S . Depar tment of Hea l th and Human Serv i ces, to const i tute the fo l lowing: the pover ty gu ide l ines for a fami l y of four d i v ided by 2000 hours or the cur rent base wage , wh i chever is h igher . At al l t imes dur ing the t erm of this cont ract , cont ractor and al l other Per formi ng Par t i es mus t pay the Base Wage (as ad j usted in accordance wi th the above) . If the payment of preva i l ing wages is requ i red for work or serv i ces done under this cont ract , and the preva i l ing wages for Covered Emp l oyees are h igher than the Base Wage , then the cont ractor and al l other Per formi ng Par t i es must pay the preva i l ing wage rates. D. The cont ractor mus t inc lude prov i s ions in al l subcont racts requi r ing i ts subcont ractors to pay the Base Wage to covered Emp l oyees. The cont ractor agrees to prov i de the Ci ty wi th documenta t i on acceptab l e to the Ch i ef Procurement Of f i cer demonst ra t i ng that al l Covered Emp l oyees , whe ther emp l oyed by the Cont ractor or by a subcont ractor , have been pa i d the Base Wage , upon the Ci ty's request for such document a t i on. The Ci ty may i ndependent l y audi t the cont ractor and/or subcont ractors to ver i fy comp l i ance herewi th . Fa i lure to comp l y wi th the requ i rements of this Sect i on wi l l be an event of defaul t under this cont ract , and fur ther , fai lure to comp l y may resul t in inel igibi l i ty for any award of a Ci ty cont ract or subcont ract for up to three (3) years. E. Not - for -Prof i t Corporat i ons: I f the cont ractor is a corporat ion hav ing Federa l tax-exempt status under Sect i on 501(c) (3) of the Interna l Revenue Code and is recogn i zed under I l l inois not - for -prof i t l aw, then the prov i s ions of Sect i on A through D above do not app l y. RESUME : Al l Unders i gneds , i nc l ud i ng "Ent i t i es ho l d i ng an interest in the App l i cant " (de f i ned on page 1 of thi s EDS) mus t comp l e t e the rema i nder of th i s EDS. SECT I ON SEVEN : NOTI CE AND ACKNOWLEDGMENT REGARD I NG CITY GOVERNMENTAL ETH I CS AND CAMPA I GN F I NANCE ORD I NANCES The Ci ty's Government a l Eth i cs and Campa i gn F i nanc i ng Ord i nances , Chapters 2-156 and 2-164 of the Ci ty's Mun i c ipa l Code , i mpose cer ta in dut i es and obl igat ions on persons seek i ng Ci ty cont racts, work , bus iness , or t ransact ions . The Ci ty of Ch i cago Board of Eth i cs has deve l oped an ethi cs t ra ining program for such persons . The ful l text of these ord i nances and the ' t ra ining program is ava i l abl e on f ine at www.c i tvofchi caao .org/Ethi cs l . and may a l so be obta i ned f rom the Ci ty's Board of Ethi cs, 740 N . Sedgw i ck St ., Sui te 500, Ch i cago , IL 60610, (312) 744-9660. The fol lowing is descr ipt i ve on l y and does not purpor t to cover every aspec t of Chapt ers 2-156 and 2-164. The Unders i gned mus t comp l y ful ly wi th the appl i cabl e ord i nances. [X] BY CHECK I NG TH I S BOX THE UNDERS I GNED ACKNOWLEDGES THAT THE UNDERS I GNED UNDERSTANDS THAT THE CITY' S GOVERNMENTAL ETH I CS AND CAMPA I GN F I NANCI NG ORD I NANCES , AMONG OTHER TH I NGS: 1) Prov i de that any cont ract negot i ated, entered into or per formed in viol at ion of the Ci ty's ethi cs l aws can be vo i ded by the c i ty. 2) Limi t the gi f ts and favors any person can gi ve , or of fer to gi ve , to any Ci ty of f icial , emp l oyee , cont ractor or cand i da te for e l ected Ci ty of f i ce or the spouse or mi nor chi ld of any of them: a. cannot g i ve them any cash gi f t or any anonymous gi f t ; and b. cannot g i ve any gi f t based an a mutua l understand i ng that the Ci ty of f icial 's or emp l oyee ' s or Ci ty cont ractor 's act ions or dec i s i ons wi l l be inf luenced in any way by the gi f t ; 3) Prohibi t any Ci ty e l ec ted of f icial or Ci ty emp l oyee f rom hav i ng a f inanc i a l interest , di rect ly or indi rect ly, in any cont ract , work , t ransact ion or bus i ness of the Ci ty, i f that interest has a cost or present va lue of $5,000 or more , or i f that interest ent i t ies the owner to rece i ve more than $2 , 500 per year. 4) Prohibi t any Ci ty appo i nted of f icial f rom engag i ng in any cont ract , work , t ransact ion or bus i ness of the Ci ty, un l ess the mat ter is who l l y unre l ated to the appo i nted of f icial Ci ty dut i es or respons ibi l i t i es. EDS 03103 For federaf l y- funded and non4ederaBy funded mat ters . Page 12 o f 13
  20. 20. 5) Prov i de that Ci ty emp l oyees and of f icials, or the i r spouses or mi nor chi ldren, cannot rece i ve compensa t i on or anyth i ng of va l ue in return for adv i ce or ass i stance on mat ters concern i ng the operat ion or bus i ness of the Ci ty, un l ess the i r se rves are who l l y unre l ated to thei r Ci ty dut i es and responsibi l i t i es. 6) Prov i de that former Ci ty emp l oyees and of f icials cannot , for a per iod of one year af ter the i r Ci ty emp l oyment ceases , ass i st or represent another on any mat ter invol v ing the Ci ty ff, whi l e wi th the Ci ty, they were persona l l y and substant i a l l y i nvo l ved in the same mat ter . 7) Prov i de that former Ci ty emp l oyees and of f icials cannot ever ass i st or represent another on a Ci ty cont ract if, wh i l e wi th the Ci ty, they were persona l l y invo l ved in or di rect ly superv i sed the formul at ion, negot i at ion, or execut i on of that cont rac t SECT I ON E I GHT : CONTRACT I NCORPORAT I ON , COMPL I ANCE , PENALTIES , D I SCLOSURE The Unders i gned unders t ands and agrees that : A. The cer t i f i cat ions, di sc losures, and acknow l edgment s conta i ned in this EDS wi l l become par t of any cont ract awarded to the Appron t by f e Ci ty in connec t i on wi th the proj ect or t ransact ion that is the sub j ect of this EDS , whe ther procurement , Ci ty ass i stancs, or other Ci ty act ion, and are mater i a l i nducements to the Ci ty's execut i on of any cont ract or tak ing other act ion wi t ty respect to ass i st ing the proj ect or t ransact ion that is the sub j ect of this EDS. The Unders i gned understands that i t mus t comp l y wi th the statutes, ord inances , and regul at ions on wh i ch this EDS is based. B. If the Ci ty de termi nes that any informat ion prov i ded in this EDS is fa lse, i ncomp l e te or inaccurate , any cont ract or other agreement in connect i on wi th wh i ch i t is submi t ted may be vo id or vo idab l e , and the Ci ty may pursue any remed i es under the cont ract (i f not vo id or voidabl e) , at l aw, or in equi ty, inc luding terminat ing the Unders i gned ' s par t i c ipat ion in the proj ect or t ransact ion and/or dec l ining to a l low the Unders i gned to par t i c ipate in other t ransact ions wi th the Ci ty . C. Some or al l of the informat ion prov i ded on this EDS and any a t tachments to this EDS may be made ava i l abl e to the pub l i c on the Internet , in response to a Freedom of Informat ion Ac t request , or otherw i se. By comp l e t i ng and s ign ing this EDS , the Unders i gned wa i ves and re l eases any poss i b l e r ights or c l a i ms wh i ch i t may have aga i nst the Ci ty in connec t i on wi th the publ i c re l ease of informat ion conta i ned in this EDS and a l so author i zes the Ci ty to ver i fy the accuracy of any informat ion submi t ted in this EDS. D. The Unders i gned has wi thhe ld no d i sc losures as to econom i c interests in the unders i gned, or under tak ing, bus iness , or t ransact ion to wh i ch this EDS per ta ins nor reserved any informat ion, da t a or p l an as to the i ntended use or purpose for wh i ch i t seeks Ci ty Counc i l or other Ci ty agency act ion. E. The informat ion prov ided in this EDS mus t be kept cur rent In the event of changes , the Unders i gned mus t supp l ement this Af f idavi t , up to the t ime the Ci ty takes act ion on the bid, proposa l , or other appl i cat ion for wh i ch this EDS is be i ng submi t ted . By: (sign hoic) Ti t le of s ignatory: Pr es i den t Pr int or type name of s ignatory: Dan i e l P - T) i P i -7. 1( - r p * I In a Repraen t a t i " oapad t y. t i p. as 11101 or agent of an App l i cant or an ent i ty (d sh i n i ng In an bngu i dua l apaer i y.) ho l f ae hand In the App i an t . ) Cau*of saes a AduvwWW under oa th on (daf t ) beb i e me by WPM - at " Not ary POW RSMV C] CYNTH I A HANKOVCAK No t ary Pub l i c , St a t e of I l l inoi s X EDS 03103 For federa l y- furded and wn- f edera l l y funded mat ters . 11 My Comm i ss i on Exp i res 0109 E f13
  21. 21. JUN 10 2003 10 : 04RN HP LRSERJET 3200 RETURN TH I S " D I SCLOSURE OF RETA I NED PART I ES " FOR I YI W I TH I N 7 CALENDAR DAYS OF C I TY NOT I F I CAT I ON D I SCLOSURE OF RETA I N E D PART I ES A. De f m l t l ons armdd D i sc l osure Reau i r emen t s 1. As used here i n , " Cont rac tor " means a person or ent i ty who has any cont rac t or l ease w i th the C i t y o f Ch i cago ( the " C i t y " ) . 2. Pursuan t to Execu t i ve Orde r 97 .1, every c i ty cont rac t and l ease mus t be accompan i ed by a d i sc l osure s t a t emen t prov i d i ng cer t a i n i n forma t i on abou t a t torneys , l obby i sts , account ant s , consu l t ant s , subcont rac tors , and other persons whom the Cont rac tor has re t a i ned or expec t s to re ta i n w i th respec t to the cont rac t or l ease . In par t i cu l ar , t he Cont rac tor mus t d i sc l ose the name o f each such person , h i s or he r bus i ness address , the na ture o f the re l a t i onsh i p , and the amoun t o f f ees pa i d or es t i ma t ed to be pa i d . The Con t rac tor i s no t requ i red to d i sc l ose emp l oyees who are pa i d so l e l y t hrough the Cont rac tor ' s regu l ar payro l l . 3. " Lobby i s t " means any person (a) who for compensa t i on or on beha l f o f any person other than h i mse l f under t akes to i n f l uence any l eg i s l a t i ve or adm i n i s t ra t i ve ac t i on , or (b) any par t o f whose dut i es as an emp l oyee o f ano ther i nc l udes under t ak i ng to i n f l uence any l eg i s l a t i ve or adm i n i s t ra t i ve ac t i on . B. C i f i ca f a Cont rac tor hereby cer t i f i es as fo l l ows : 1. Th i s D i sc l osure re l a tes to the fo l l ow i ng t ransac t i on : Spec i f i ca t i on or o ther i dent i f y i ng numbe r : L 1) t r 8 1) °) 0031 CC o . t [R!>c7 : A r rv g t { CaZO ) 12 S ) Descr i pt i on o f goods or serv i ces to be prov i ded unde r Cont rac t : PaDF D f t 1c a . SCC%AtE s Mr3 . JRoE %T . / 2. Name o f Cont rac tor : _ ' PCT2 t - . E~ ~~ rc . E~~r. oG w~. 3. EACH AND EVERY a t torney , l obby i st , accoun t an t . consu l t ant , subcont rac tor , or o ther person re t a i ned or ant i c i pa t ed to be re t a i ned by the Con t rac tor w i th respec t to or i n connec t i on w i th t he cont rac t or l ease is l i sted be l ow . At t ach add i t i ona l pages i f necessary . NOTE : You mus t i nc l ude i n forma t i on abou t cer t i f i ed MBE I WBEs you have re t a i ned or ant i c i pa t e re ta i n i ng , even i f you have a l ready prov i ded that i n forma t i on e l sewhe re i n the cont rac t documen t s. RELAT I ONSH I P FEES ( i nd i ca t e BUS I NESS (a t torney , l obby i s t , whe t he r pa i d or NAME ADDRES5 subcont rac tor , t i c. ) es t i ma t ed) CoITEl - C0N5%A. ' t% , 1q i Wt - 15q S . 1AA t. 4k j t . *yz . S-0a (o , 1VAc ' t a (L. 71DN . (of f PA` ' ~ k C ee i Y-+oa E,+1%-?J EU N , t , i e. 3o E. r~w^r " i A l koo S Q Cor ' t 2AC?o2 Uu Se . a t ~A , ~ ' ryE s' i P fo t F t wa ~r,)tr . Zo E . (I1 c -~ SJ3 Cs*~ ' To f e. °1 °1 t 3 a 3 ~~ CHECK HERE IF NO SUCH PERSONS HAVE BEEN RETA I NED OR ARE ANT I C I PATED TO BE RETA I NED :
  22. 22. JUN 10 e~UU3 10 : U4r , i - , HP LRSERJET 3200 4. The Con t rac tor unders t ands and agrees as fo l l ows : - a. -Th l L- - i nforma t ro , , prov i ded-here i n- i s-ama t er i a[ i nducement - to t3te C i Ws - t xecu t i o t t o f the cont rac tor other ac t i on w i t h respec t to wh i ch th i s D i sc l osure o f Re t a i ned Par t i es f orm i s be i ng execut ed , and the C i t y may re l y on the i n forma t i on prov i ded here i n. Fur thermore , i f the C i t y de t e rm i nes tha t any i n forma t i on prov i ded here i n i s fa l se , i ncomp l e t e , or i naccura t e , the C i t y may t erm i na t e the cont rac t or other t ransac t i on , t erm i na t e the Cont rac tor ' s par t i c i pa t i on in the cont rac t or other t ransac t i on , and / or dec l i ne to a l l ow the Con t rac tor to par t i c i pa t e in other cont rac t s or t ransac t i ons w i th the C i t y. b . I f the Con t rac tor i s uncer t a i n whe t he r a d i sc l osure i s requ i red unde r the F-xccut i ve Order , the Cont rac tor mus t e i ther ask the Cont rac t Adm i n i s t ra tor or h i s or her manage r whe t he r d i sc l osure i s requ i red or make the d i sc l osure . c. Th i s D i sc l osure o f Re t a i ned Par t i es form , some or a l l o f the i n forma t i on prov i ded here i n , and any a t t achmen t s may be made ava i l ab l e to the pub l i c on the Interne t , i n response to a F r eedom o f In forma t i on Ac t request , or o therw i se . The Cont rac tor wa i ves and re l eases any poss i b l e r i ghts or c l a i ms i t may have aga i ns t the C i t y in connec t i on w i t h the pub l i c re l ease o f i n forma t i on cont a i ned i n the comp l e t ed D i sc l osure o f Re t a i ned Par t i es f orm and any a t t achmen t s. Unde r pena l t y o f per j ury , I cer t i fy tha t 1 am author i zed to execu t e th i s D i sc l osure o f Re t a i ned Par t i es on beha l f o f the Con t rac tor and tha t the i n forma t i on d i sc l osed here i n i s t rue and comp l e t e - S i gna ture J Da t e I e O S SE~J ~ o2 V N LE l u sl oE ` ~ Name ( t ype or pr i nt ) Ti t le Subsc r i bed and swom to be fore me th i s day o f t , ~- 03 ?b OFF I CI AL SEAL MARTA M OLAGUE NOTARY PUBLIC - STATE OF ILLINOIS MY COMM I SS I ON EXPIRES 09 . 1946 SI
  23. 23. RrRN TH I S " D I SCLOSURE OF RETA I NED PART I ES " FORM W I TH I N 7 CALENDAR DAYS OF C I TY NOT I F I CAT I ON D I SCLOSURE OF RETA I NED PART I ES A. De f i n i t i on s and D i sc l osure Reou i r emen t s 1. As used here i n , "Cont rac tor " means a pe rson or ent i ty who has any cont rac t or l ease w i th the Ci ty o f Ch i cago ( the "Ci ty" ) 2. Pursuan t to Execut i ve Orde r 97-1 , every c i ty cont rac t and l ease mus t be accompan i ed by a d i sc l osure s t a t emen t prov i d i ng cer t a i n i n forma t i on abou t a t torneys , l obby i s t s . accoun t an t s , consu l t ant s , subcont rac tors , and o ther pe rsons whom the Con t rac tor has re t a i ned or expec t s to re t a i n w i th respec t to the cont rac t or l ease . i n par t i cu l ar , the Con t rac tor mus t d i sc l ose the name o f each such pe rson . h i s or her bus i ness address , the na ture of the re l a t i onsh i p , and the amoun t of f ees pa i d or es t i ma t ed to be pa i d . The Con t rac tor is not requ i red to d i sc l ose emp l oyees who are pa i d so l e l y t hrough the Cont rac tor ' s regu l ar payro l l . 3. "Lobby i s t " means any person (a) who for compensa t i on or on beha l f of any person other t han h i mse l f unde r t akes to i nf l uence any l eg i s l at i ve or adm i n i s t ra t i ve ac t i on , or (b) any par t of whose dut i es as an emp l oyee of ano t he r i nc l udes under t ak i ng to i nf l uence any l eg i s l at i ve or adm i n i s t ra t i ve ac t i on . B. Cer t i f i ca t i on Con t rac tor he reby cer t i f i es as fo l l ows : 1. Th i s D i sc l osure re l a t es to the fo l l ow i ng t ransac t i on : MONROE STREET BR I DGE Spec i f i ca t i on or o ther i dent i f y i ng numbe r : C968-99-0037 Descr i pt i on o f goods or serv i ces to be prov i ded unde r Con t rac t : Arch i t ec tura l and Eng i neer i ng Des i gn 2. Name of Con t rac tor : Pa t r i ck Eng i nee r i ng , Inc. 3. EACH AND EVERY a t torney , l obby i s t , accoun t an t , consu l t an t , subcon t r ac t or . or o t he r pe rson re t a i ned or an t i c i pa t ed t o be re t a i ned by t he Con t r ac t or w i t h respec t to or i n connec t i on w i t h t he con t rac t or l ease is l i st ed be l ow. At t ach add i t i ona l pages i f necessa r y. NOTE: You mus t i nc l ude i n f orma t i on abou t cer t i f i ed MBE / WBEs you have re t a i ned or an t i c i pa t e re t a i n i ng , even i f you have a l ready prov i ded tha t i n f orma t i on e l sewhe r e i n t he con t rac t documen t s . RELAT I ONSH I P FEES BUS I NESS (a t torney , l obby i st , ( i nd i ca te whe t he r NAME ADDRESS sub-cont rac tor . e t c .) pa i d or es t i ma t ed) COTTER CONSULT I NG . I NC. 150 S Wacke r Dr . . Su i t e 420 sub- con t r ac t or $7634 . 64 od Techknow Eng i nee rs . LLC 30 E. Adams St . . Su i t e 1 100 sub- con t r ac t or $44 . 856 . 04 [ )d Bes t Pho to Dra f t i ng . Inc . 20 E. Rando l ah St . sub-cont rac tor $9 . 913 . 93 ad CHECK HERE IF NO SUCH PERSONS HAVE BEEN RETA I NED OR ARE ANT I C I PATED TO BE RETA I NED :
  24. 24. The Cont rac tor unders t a i and agrees as fo l l ows . a . The i n forma t i on prov i ded here i n is a ma t er i a l i nducemen t to the Ci ty ' s execu t i on of the cont rac t or o ther ac t i on w i th respec t to wh i ch th i s D i sc l osure of Re t a i ned Par t i es Corm is be i ng execu t ed , and the C i t y may re i v on the i n forma t i on prov i ded here i n . Fur t he rmore , i f the C i t y de t e rm i nes tha t any i n forma t i on prov i ded here i n is fa l se , i ncomp l e t e , or i naccura t e , t he C i t y may t e rm i na t e t he con t rac t or o t he r t ransac t i on , t erm i na t e the Cont rac tor ' s par t i c i pa t i on in t he con t rac t or o ther t ransac t i on , and / or dec l i ne to a l l ow the Con t rac tor to par t i c i pa t e i n o t he r cont rac t s or t ransac t i ons w i t h the C i t y . b. If the Cont rac tor is uncer t a i n whe t he r a d i sc l osure is requ i red unde r the Execut i ve Order , the Cont rac tor mus t e i ther ask the Cont rac t Adm i n i s t ra tor or h i s or her manage r whe t he r d i sc l osure is requ i red or make the d i sc l osure . c. Th i s D i sc l osure of Re t a i ned Par t i es form, some or al l of the i nforma t i on prov i ded here i n , and any a t t achment s may be made ava i l ab l e to the pub l i c on the Internet , in response to a F r eedom of Informa t i on Ac t request , or otherw i se . The Cont rac tor wa i ves and re l eases any poss i b l e r ights or c l a i ms it may have aga i nst the Ci ty in connec t i on w i th the pub l i c re l ease of i nforma t i on con t a i ned in the comp l e t ed D i sc l osure of Re t a i ned Par t i es form and any a t t achmen t s . Unde r pena l t y of per j ury , I cer t i fy tha t I am author i zed to execut e thi s D i sc l osure of Re t a i ned Par t i es on beha l f of the Con t r c tor and that the i nforma t i on d i sc l osed here i n is t rue and comp l e t e . Jo t ~ j l ~J / a -0 ~- -~o S i gna ture Da t e Name hype or pr int ) Ti t l e Subscr i bed and sworn to be fore me a. thi s 2 Y day of Pe c e - b , e r , 20 Rev . 11 / 99 2

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