name: ainendhhent,opendocs.cookcountyil.gov/procurement/modifications/11...ainendhhent, no, 4...
TRANSCRIPT
AINENDHHENT, NO, 4
Contract No. 11-53-1858Vendor Name: AUTOMOTIVE TECH CENTER
This Alnsndment modifies Contract No, 11-53-185B,for Automobge Maintenance and Repair for Zone 2 by and
between the County of Cook, HHnois, herein referred to as "County" and Automotive Tech Center, authorized to do
business in the Sale of!Hinois hereinafter referred to as "Contractor'.
RECITALS
Whereas, the County and Contractor have entered into a Contract approved by the County Board on October 16,2012, (hereinafter refenad to ss the "Contract" ), wherein the Contractor is to provide Automotive Maintenance and
Repair for Zone 2 (hereinafter referred to as the "Services") from November 1, 2012 through October 30, 2015, with
two, one-year renewal options, in an amount not to exceed $289,100.00;and
Whereas, Amendment 6 I was executed on April 3, 2014 for an increase cf$149,000.00;and
Whereas, Amendment if 2 was authorized by the County Board on June 18, 2014 and executed on July 2, 2014 for
an increase of $100,000,00; and
Whereas, Amendment 6 3 was authorized by the County Board on April 29, 2015 and execubxt on May 13, 2015 for
an increase of $46500000 and for a renewal period of November 1, 2015 Ihrough October 30, 2016; and
Whereas, s renewal is deslmd for the continuation of Services; and
Whereas, an incmase in the amount of $188,000.00is required for the continuation of Services; and
Whereas, the County and Contractor desire to renew the Contract for twelve months beginning cn November 1,2016through October 30, 2017.
Now therefore, in consideration of mutual covenants contained herein, it is agreed by end between ths parties toamend the Contract as follows:
1. The Contract is renewed Ihmugh October 30, 2017.
2. The Contract is increased by $188 000 00 and the Total Contract Amount is revised to $1,191,10000.
3, GC-04 Pavment of the Contnuri Is deleted in its entirety and Is revised ss follows:
AH invoices submitted by the Consultant shaH be in accordance wgh gie cost provisions contained in theContract and shall contain a detailed description of the Deliverables, including the quantity of theDeliverables, for whhh payment is requested. AH invoices for ssniices shall inrriuds itemized entriesIndicating the date or time period in which the services warn provided, ths amount of time spent performingths services, and a detaged descriptio of the services proirided during the period of the invoice. AH
invoices shay reflect the amounts invoiced by snd the amounts paid to the Consulbmt as of the dale of theinvoice. Invoices for new charges shall not indude "past due" amounts, iT any, which amounts must be setforth on a separate invoice. Consultant shall not be entitled to invoice the County for any late fees or otherpenalties.
In accordance with Secgon 34-177 of the Cook County Procurement Code, the County shall have a d'ght toset ofi and subtract from any invoice(sl or Conbact price, a sum equal to any fines and penalties, including
interest, for any tax or fee delinquency and any debt or obligation owed by the Consultant to the County.
Rcv i/i/15
Contract No, tf-53-185BVendor Name: AUTOMQTiVE TECH CENTER
The Consuhant acknowledges its duty to ensure the accuracy of all invoices submitted to the County forpayment. By submitting the invoices, the Consultant certifies that all Itemized entries set forth in theInvoices are true and conact. The Consultant aclmowledges that by submitting the invoices, It certifies thatit has delivered the Deliverables, i.e., the goods, supplies, services or equipment set forth in the Contract tothe Using Agency, or that it has properly perhrmed the services set forth in the Contract. The invoice mustalso reflect the dates and aihount of time expended in the provision of services under the Contract TheConsuihtnt acknowledges that any inaccurate statements or negligent or intentional misrepresentations in
the invokes shall result In the County exercising all remedies available to it in law and equity Including, butnot limited to, a delay in payment or non-payment to the Consultant, end reporting the matter to the CookCounty Olfice of the Independent Inspector General.
When a Consultant receives any payment fran the County for any supplies, equipment, goods, or servkes,it has provided to the County pursuant to ils Contract, the Consultant must make payment to its
Subcontractors within 15 days after receipt of payment from the County, provided that such Subcontractorhas satisfactorily provided the supplies, equipment, goods or services in accordance with the Contract andprovided the Consultant a/dh all of the documents and information required. of the Consultant.. TheConsultant may delay or postpone payment to a Subcontractor when the Subcontractors supplies,equipment, goods, or services do not comply with the requirements of the Contract, ihe Consultant is achngin good faith, and not in retaliation for a Subcontractor exercising legal or contractual rights.
4. The attached Economic Disclosures Statement, Identification of Sub-Contractors/Suppliers/Sub-ConsultantsForm and MBE/WBE Utilization Plan forms ane incorporated and made a part of this Contract,
5. All other terms and condigons remain as stated in the Contract
In witness whereof, the Couniy and Contractor have 'caused this Amendment No. 4 to be executed on the date andyear last wiitten below,
County of Cook, Illinois
Signed ~Type or print name
IZ J~ Date: 8/orr~ 't. Sr T /4
Rev i/i/ls
Contract No. 11-53-186BVendor Name. 'AUTOMOTIVE TECH CENTER
ATTACHMENT
Rev t/I/15
CONTRACT NO. 11-53-185B
Cook CountyOffice of the Chief Procurement Officer
Identification of Subcontractor/Supplier/Subconsultant Form
QCPO ONLY:~hgu~~nCl Cbedr~Com I e
The Bidder/Proposer/Respondent Nlm Contractor" ) will fully complete and execute and submit an Identification olSubcontractor/Supplier/Subconsullsnt Form ("ISF")with each Bid, Request fcr Pmposal, and Request forQuallficatlon. TI» Contractor must complete the ISF for sach Subcontractor, Supplier or Subconsultant whichshall be used on the Contract. In the event that them sre any changes in the utilization of Subcontractors,Suppliers or Submnsultsnts, ths Contractor mutt file an updated ISF.
Bid/RFP/RFQNo.: /I ~f~ES 8 '4V 0 4&/TctalgldcrprocosalAmount; / Ãi0/r< ' RPAs>~
Subcontracts//Suppfier/Contractor, ~Mr//)/H v / Subconsultantlc bs ~~j„<g Q<»Jmcf4 (-M~7 v/ . added or subsgtute:
Authorized Cordsct for
Email Address Emafi Address(Conlractor): X / 77v'a&/8 dc'l, r ~ .(subcontractor): 2 c's'dr' C lrr/ Wz'M~, / mj
I
Company Addn»s(Contractor): ~~ ~+ ~+ (Subccntrsctcrr. /-'zS
City, Stats and Cgy, State and ZipBc (Conbsctcr): 4(FR ACME, 32 fpP5 M (Subcontractor): Burr~ i.W~,W / 4/)'5 A"'9-Telephone and Fax ( gc'@'~p- /r/." fp, 'elephone and Fsx $ &JI zr3 g 4 /-(Contractor) r P/)M ~4 r. d (Subcontractor) /) Xo/ d/ (' qr @f=
3'stimatedgtartendk'stimatedglartand~Completion Dates Completion Dates(contractor) Akv. /~M4&s'o~ (subcontractor) /4(/../.toft —()~+ ~ g.z//7
Nels, 'Upon request, a copy of all written subcontractor agreements must be provided to the OCPO.
Total Price cgDsscricuon of Services cr Sucolies Subcontmct for
Services or Su»»ries
A/c~uaX-, p 4~ .,lWaHi~~ ~~~>(m~The subcontract documents will incorporate all requimments of the Contract awarded to the Contractor as applicable.The subcontract will in no way hinder g» SubcontrsdcrlSupplier/Subconwultent fmm miinlainlng its prcgnxm on anyother contract on whbh it is either a Subcontractor/Supplier/Subccnsultarrt or principal ccnbuctor. This dlsckuure isnude with the understanding that the Contractor is not under any circumstances relimmd cf its abSies andobligations, and br n»ponsible for the organization, perfonnance, end quality of work. This form does not approvesny proposed changes, revisions or modltloatlons fo the contmct apprvtved MBE/WSE UUllzatlon Plan. Anychanges to U» contract's approved MBE/WSEIUUItzagon Plan must be submitted to ths Of/ice of theContmct Compgsncu
7e' C~'7
F„7/7iAE Lk,~ <.Xa~r„
prime ContracTor ~tureen Date /
ISF-1 5/2C15
OFFICE OF CONTRACT COMPLIANCE
JACQUEUNE GOMEZ
DIRECTOR
116 N. Clark, County Building, Room 1020 ~ Chicago, Illinois 60602 ~ I312) 603-5502
May26,2016
TONI PRECKVVINKLE
PRESIDENT
Cook County Board
of Commissionms
RICHARD R. BOYRIN
1st District
ROBERT Si EELE
2nd Distnct
JERRY BUTLER
3rd District
STANLEY MOORE
4th District
DEBORAH SIMS
5th District
JOAN PATRICIA MURPHY
6th District
JESUS G. GARCIA
7th District
LUIS ARROYO, JR
6th Distnct
PETER N, SILYESTRI
9th District
BRIDGET GAINER
10th District
Ms. Shannon E. Andrews
Chief Procurement Oflicer
118N. Clark Street
County Building-Room 1018
Chicago, IL 60602
Re: Contraot No. 11-53-185B(Amendment No. 4)Automobile Maintenance and Repair for Zone 3Transportation and Highways
Dear Ms. Andrews:
The Ollice of Contract Compliance is in receipt of the above-reference contract amendment and has reviewedit for compliance with the Minority- and Women- owned Business Enterprises (MBE/WBE) Ordinance, Attercareful review, it has bmm determined this amendment is responsive to the Ordinance.
Bidder: Automotive Tech Center
Original Contract Value: $289,100.00Incnmsed Contract Value: $149,000.00(Amendment No. 1)New Contract Value: $438,100.00Incrmumd Contract Value: $100,000.00(Amendment No. 2)New Contract Value: $538,100.00Increased Contract Value: $465,000.00 (Amendment No. 3)New Contract Value: $1,003,100.00Increased Contract Value: $188,000.00(Amendment No. 4)New Contract Value: $1,191,100.00Extended Contract Tenn: 12 months
New Contact Term: November 1, 2016 through October 30, 2017Contract Goal: 30% overall MBE/WBE
JOHN P. DALEY
11th District M BE/WBE
Leslie A. Ceaario, Ltd.
~Statu Certifvina Aaencv
WBE (7) Cook County
Commitment"
30% (Indirect)JOHN A. FRITCHEY
12th Distdict
LARRY SUFFREDIN
13th Distdict
'Commitment percentages are based on the new contract value.
Revised MBE/WBE forms were used in the determination of the responshmness of this contract.
GREGG GOSUN
14th District
IIMOTHY O. SCHNEIDER
15th District
JEFFREY R. TOBOLSIO
16th District
SEAN M. MORRISON
17th Distdict
Sincerel,
Jacqueline Gomez
Contract Compliance Director
JG/ate
Cc: Barbie Flock, OCPO
Nicki Cannatello, DOTH
Enclosures: Revised MBE/WBE forms
$ Fiscal Re'sponsibgity P Innovative Leadership Trsnsperency st AccountsbilityQk Improved services
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OFFICE OF CONTRACT COMPUANCE
JACQUELINE GOMEZ
DIRECTOR
118 N. clark, county Building, Room 1020 o chicago, Blinois 60602 ~ (312l 603-5502
TONI PRECKWINKLE
PRESIDENT
Cook.County Board
of Commissioners Apnl 22, 2016
RICHARD R. BOYKIN
1st District
ROBERT STEELE
2nd Distrkt
JERRY BUTLER
3rd Distrkt
STANLEY MOORE
4th District
DFBDRAH SIM5
5th Dlsokl
JOAN PATRICIA MURPHY
6th Disuin
JESUS G. GARCIA
7th Distrld
LUIS ARROYO, JR.
6th District
PETER N. SILVESTIR
Sill Dislrin
BRIDGET GAINER
10th Dlstrkt
JOHN P. DALEY
11th Dislrkt
NA Efi(A/L /ea/legJsccps.nefMs. Lsslie A. Cesario, PresidentLeslie A. Cesario, Ltd.1813Marengo Court
Napervfils, IL 60564
Re; Cook County MBE/WBE/f/BE Cerlification Exterlsion
Dear Ms. Cesario:
please be advised that your BMtus as a cerfified Mlrority'usiness Entsipdss (MBE), women's BusinessEnterprise (wBE) and/or veteran Business Eriterprise (vBE) has been extended untfi June 22, 201B,
This extension is provided to ensure a thorough review of your company's documentation and tou allow. your
company the time to Submit additionalinformation and documents if requested.
This Certification Extension does not guarantee confinusd eiigibikty in Cook County's MBE/INBE/VBE
Program.
In responding tc piocuremsnt opporturtiTies, as evidence of your current MBE/WBE/VBE Deification with
Cook County, you may include this Extension Letter and most recent Cermicalion Letter with your subimssion.~, .I:
If you have sny questkms, plssss ftad free tc contact Laura Russo at (312)603HI700.
Btnoslsly,
JOHN A. FRtTCHEY
12thDistric'ARRY
SUFFREDIN
13th District
GREGG GOSUN
14th Dlslrin
Lisa AlexanderContract Compfiance Deputy Director
LA/lar
TIMOTHY O.5CHNHDER
15th District
JEFFREY R. TOBIXSKI
16th Dlstrib
SEAN:l4I. MORRtSON
1'7th District
$ Fiscal Responsibsity f lrtnovative Leadership Transparency Et Accountability krt Improved Services
CONTRACT NO. 11 63 185B
ATION —FORM 3PETITION FOR REDUCTION/WAIVER
A. BIDDENPROPOSER HEREBY REQUESTS:
FULL MSE WAIVER FULL WBE WAIVER
H REDUCTION (PARTIAL MBE and/or WBE PARTICIPATION)
% of Reducgon for MBE Parficipatlon
% of Rsduc5om for WBE Psrgdpstion
REASON FOR FULUREDUCTION WAIVER REQUEST
Bidder/Proposer shall check each item sppficable to its reason for a waiver rsquesL Addifionafiy, supporting
documsrdalion shall be submitted with this mquest.
(I) Lack of sufficient quafified MBEs and/or WBEs capable of providing Ihe goods or services required
by the contract. (Please explain)
(2) The specglcatlons snd necessary requirements for perhrming the contract make it impossible oreconomlcagy Infesm'ble to divide the contract to enable Ihs contractor to utilize MBEs and/or WBEsin accordance with Ihe applicable parhdpafion. (Please explain)
(3) Price(s) quoted by ptdenfial MBEs and/or WBEs are abmm competitive levels and increase cost ofdoing business and would make sccephmce of such MBE and/or WBE bid economically
impmcticable, taking into consideration the pementage of lofti contract pdce represented by suchMBE snd/or WBE bid. (Please explain)
(4) There are other rehrvant factors making it impassible or economically infeasible to utilize MBEand/or WBE firms. (Please explain)
C. GOOD FAITH EFFORTS TO OBTAIN MBBWBE PARTICIPATION
(I) Made timely writhm soficitstlon to Iden55ed MBEs and WBEs for utilization of goods and/or
services; and provided MBEs and WBEs with a timely opportunity to review and obtain relevant
specifications, terms and condiTions of the proposal to enable MBEs and WBEs to pmpam aninformed response lo solicitation. (Attach of copy writhe solicitstl one made)
(2) Used the services and assistance of the Office of Contract Compliance siaff. (Please explain)
(3) Timely notTiied and used the services and assistance of community, minority and women
business
mgsniza5ons, (ANach of copy wriNsn soficitstions made)
(4) Fofiowed up on iriigal solicitatlon of MBEs and WBEs to determine if firms are intsreslsd in doingbushwss. (Attach supporting documentation)
(5) Engaged MBEs 5 WBEs for direct/kttgmct participagon. Please explain)
D. OTHER RELEVANT INFORMATION
Attach any other documenhrgon relative to Good Faith Efforts in complying with MBE/WBE pa bcipalion,
rvt/vvez Reduction/vvarver Request - Form 3 Revised: OZ/Ze/14
CONTRACT NO. 11-63-166B
COOK COUNTYECONONIIC DISClOSURE STATEMENT
AND EXECUTION DOCUMENTINDEX
Section Description Peace
Instructions for Completion of EDS
CertNcatlons
Economic and Other Disdosurss, Ailklavit of Child
Support Obligations, Disdosure of Ownsnrhip Interestand Familial Relagonship Disclosure Form
Cock County Affi'davR fcr Wage Theft Ordinance
Contract and EDS Execution Page
Cook County Signature Page
EDS i - ii
EDS1-2
EDS3-12'DS
13-14
EDS 16-17
EDS 18
CONTRACT NO. 11-63-1888
SECTION 1INSTRUCTIONS FOR COMPLEIfON OF
ECONONIIC DISCLOSURE STATEBIENT AND EXECUTION DOCUISENT
This Economic Disclosure Statement snd Execution Document CEDS"I is ia bs completed and executedby every Bidder on 8 County conbact, every Proposer responding to s Request for Proposals, and everyRespondent responding to a Request for QualiTicsfions, and others as required by the Chief ProcurementOflicer. The iuiscution of the EDS.shall serve as the execution of a contract awarded by the County. The.Chief Procurement Ogicer reserves the right to request that ths Bidder or Proposer, or Respondentprovide an updated EDS on an annual basis.
Definitions, Terms used in this EDS and not ogterwise defined herein shall have the meanings given tosuch terms in lhs Instruotlons to Bidders, Gsneml Conditions, Request for Proposals, Request forQualifications, as appllcabls.
Alfflists means a person that directly or indirectly through one or more intermediaries, Controls isCcntmllsd by, or ie under common Conbal with the Person specified.
Applicant means e person who executes Ibis EDS.
Bidder means any person who submits a Bid.
Code means the Cade of Ordinances, Cook County, illinois available on munkxide.corn.
Contract shall include sny written document to make Piocursments by or on behalf of,Ccak Caunty.
'
Contractor ar Conirscifng Party means a person that enters into a Contract with theCounty.
Confml means the unfetbued authority to directly or indirectly manage governance,admlnisbation, work, and sll other aspects of s business.
EDS means this comphte Economic Disdosure Statement snd Execution Document,including tgi sections listed in ths Index snd any attachments.
Joint Irenfurs means an association of two or more Pemons proposing to perform a for-profit business enterprise. Joint Ventures must have an agreement in wiTing specifyingthe terms snd condiTions of the relationship between the partners and their relationshipand isspschys responsibility for the Conbact
Lobby or lobbying means to, for compensation, attempt to influence a County official orCounty employee with respect to any County matter..
Lobbyist means any person who lobbies.
Person or'ersons means any individual, corporation, partnership, Joint Venture, trust,association, Limited LiabiTity Company, sde proprietorship ar other legai entity.
Probibfsd Acts means any of the actions or occurrences which form the basis fordisqualificabon under the Code, or under the Certiflcations hereinafter sst forth.
Pmposal means a response ta an RFP.
Pmpcssr means a person submitting a Proposal.
Response means response to an RFQ.
Respondent means a person responding to an RFQ.
RFP means a Request for Proposals issued pursuant to this Procurement Code.
RPQ means 8 Request for Qualifications issued to obtain the qualifications of interested parties.
EDB-i BI2015
GONTRACT NO. 11-53d555
INSTRUCTIONS FOR COMPLETION OFECONOMIC DISCLOSURE STATEMENT AND EXECUTION DOCUMENT
Section 1:Inslructhns. Section 1 sets forth the instructions for completing and executing this EDS.
Section 2: CertMcations. Section 2 sets forth csrSTications that are mquirsd for contracting parties underthe Code and other applicable laws. Execution of this EDS consRutes a warranty that all the statementssnd certifications contained, snd all the facts stated, in the Certifications sre true, correct and compkde asof ths date of execution.
Section 3:Economic and Other Disclosures Statement. Sscgcn 3 is the County's required Economicand Other Disdosures Staiement form. Exscudon of this EDS consbtutes a warranty that aII theinformation provided in the EDS Is true, correct and complete as of the date of execution, and binds theApplicant to the warranties, representations, agreements and acknowledgements contained therein.
Required Updates. Ths Applicant is required Io keep all information provided in this EDS current andaccurate. In the event of any change in ths Informagon provided, Indudlng but not limited to any changewhich would render inaccurate or incomplete any certification or statement made in this EDS, theApplicant shall supplement this EDS up to the tkne the County takes action, by fSng an amended EDS orsuch other documentation as is required.
Additional information. The County's Governmental Ethics and Campaign Financing Ordinancesimpose certein duges and obligagons on persons or entities seeking County contracts, work, business, ortransactions, snd the Applicant ls expected to comply fully with these ordinances. For further informationplease contact the Dimotor of Ethics at (3'l2) 6034304 (Bg W. ylfwshlngtod St. Suite 3040, Chicago, IL6050'2) or vidt Ihe web-site at cookccuntyil. gov/ethics-board-of.
Authorized Mgnsrs of Contract snd EDS Exacutton Page. If the Applicant is a corporation, thePresident and Secmtary must execute ths EDS. In the event that this EDS is executed by someone otherthan the President, attach hemto a cerlilied copy of that secdcn of ths Corporate By-Laws or. otherauthorization by Ihe Corporation, sslisfactory to the County that permits the person to execute EDS forsaid corporation. If the corporathn is not rsgistemd in ths State of illinois, a copy of the Csrtlgcats ofGood Standing from the state of incorporation must be submitted with this Signature Page.
If the Applicant Is a partnership or joint venture, all partners or joint venturers must execute the EDS,unless one partner or joint ventum has been authorized to sign for the partnership or joint venture, inwhich case, the partnership agreement, resolution or evidence of such authority satisfactory to the Ofgceof the Chief Prccuremsnt Oflicer must bs submitted with this Signature Page.
If the Applicant Is a msmbsr4nanaged Li.C all members must execute the EDS, unless olherwisepmvided in the operating agreemsnt, resolution or other corpomta documents. If the Applicant is amanager-mansged LLC, the manager(s) must execute the EOS. The Applicant must attach either acertified copy of the operating agmement, resolugon or other authorization, sagsfactory to the County,demonstrating such pemon has the authority to execute the EDS on behalf of the LLC. If the LLC Is notregistemd in the State of illinois, s copy of a current CertNcate of Good Standing from the state ofincorporation must be submitted with this Signature Page.
If the Applicant is a Sole Proprietorship, the sole proprietor must execute the EDS.
A "Partnership" 'Joint Venture" or 'Sole Proprtetcrship" operating under an Assumed Name must beregistered with the Illinois county in which it is located, as provided in 805 ILCS 405 (2012},anddocumentation evidencing registration must be submitted with ths EDS.
EDS-ii
SECTION 2
CEITTIFICATIONB
CONTRACT NO. 11-53-185S
THE FOLLOWING CERTIFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE. THE APPLICANT ISCAUllONED TO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE SIGNTNGTHE SIGNATURE PAGE SHALL CONSllTUTE A WARRANTY BY THE APPLICANT THAT ALL THE STATENIENTSCERTIFICATIONS AND INFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE ANOCORRECT AS OF THE DATE THE SIGNATURE PAGE IS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTYLEARNS THAT ANY OF THE FOLLOWING CERTIFICAllONS WERE FALSELY MADE, THAT ANY CONTRACT ENTEREDINTO WITH THE APPLICANT SHALL BE SUBJECT TO TERMINATION.
A. PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATION
No person sr business entity shall be swarded a contract or sub~ah for a period af five (5) years finm the date ofconviction or snby of a plea or admhaiion of guilt, chal or criminal, if fiwt person ar buirinmm enfity:
1) Has been convicted cf sn aat aommitled, within the Stats of filinois, of bribery or attempting to bribe an aNcaror employee of a unfi of slate, federal or local government or school dtstrict in ths State of Illinois in thatoificers or employee's oNclsl capacity;
2) Hss been convicted by federal, stats or local government of an «ct of bid-rigging ar sttempfing to rig bids esdelined in the Sherman Anti-Trust Act and Clayton Act. AcL 15 U.S.C. Section 1 et seg.;
3) Has been convicted af bid-rigging or attempting to rig bids under the laws of federal, shris or localgavwrllliluit,')
Hss been convicted of an act committed, wfihln the Stats, of price-fixing or attempting to fix price as definedbyihs Sherman Anti Trust Act and the Qsyton Act. 15 U SC. Section 1, et sea,
5) Has been convicted of prics-fixing or attempting to fix prices under the laws ths Sate;
6) Has been convicted of defrauding or attempting to defraud any unit of stale or local government or schooldislrirfi within the State af filinois;
7) Has made sn admission of gugt of such conduct as set forth In subsections (1) through (8) above whichadmission is a matter of record, whether or not such person or business enNy wss subject to prosecution forIhe affsnse or offenses admitted to; or
8) Has entered a plea cf inde contendere to charge of bribery, price-fixing, bidmgging, or fmud, as sel forth in
subtmregraphs (1) through (6) above.
In the case afbribery or attempfing to bribe, a business entlhr may not be awarded a aontmct if an oNaial, agent oremployee of such business enNy committed the Pmhlbited Act on l»half af the business entity and pursuant to thedlrscfion or aulharixatfon of an oNcsr, director or olhsr responBible cNrfial of Ihe business entity, and such prohibitedAct occunsd wfihin tlime years prior to the award of the contract. In sddiTion, a business enlity shall bs disquslified If anowner, parlner or shareholder conlrofiing, diredly ar indirectly, 20% or more of the business entity, or an afiicer of thebusiness enNy has performed any Prohibited Act wfihin five years prior to the sward af ths Contract.
THE APPLICANT HERESY CERffPTES THAT The Applicant has mad the provisions of Section A, Pen»ns andEn5tles Subject Io Disqusfificsfian, that the Applicant has nat commBed eny prohlbfied Act set forth In Secfion A, sndthat award of the Contract to the Appficant would not violate ths provisions of such Secfion ar of the Code.
B. BID-RIGGING OR BID ROTATING
THEAPPLICANT HERESY CERTIFIES THAT: ih acconfsnce wilb 720 ILCS 5r33 E 51, neither the Apfricenf nor anyAfifiiated EnNy is barred fram swenl of this Canbacf ss a »suit af s canviciion far the vioiefian of Stale lese prohibitingbid-n'gging or hfd ratefing.
C. DRUG FREE WORKPLACE ACT
THE APPLICANT HEREBY CERTTFTES THAT: The Applicant wifi pnwlde a dmg free waApbrce, as requ'esd by (30 ILCS580/3).
EDS-1 SI2015
CONTRA'GT NO. 11-63.135B
D. DELINQUENCY IN PAYMENT OF TAXES
THE APPLICANT HERESY CERTIFIES THAT: The Wp))cent is not sn awnsr or s party responsible for fhe payinsnf ofany fax or Ss administered by Cook Coun(y, by s local municipality, sr by the illlnals Depanment of Revenue welch suchfax orfss is rhgngusnt, such as bw award of s contmcf orsubcon!rect pursuant to the Cade Chapter 34, Season 34 171.
E. HUMAN RISHlS ORDINANCE
No person who Is s party to a contract usth Gook Gouniy ("Gaunt/) shall engage in unlawful dlscriminagon or sexualharassment against any individual in the tenne or conditions of empkryment, credit, public accommodations, housing, orprevision af County faagltiss, servkes ar programs (Code Chapter 42, Secgon 4240 et sag ).
F. ILLINOB HUMAN RIGHTS ACT
THE APPUCANT HEREBY CERTIFIES THAT: It ls in camPlisnce wBr grs Illinois Human Rights Act (f75 ILCS 6r2106),snd agrees fa abide by the mrpdrements af the Act as pert of lie contmctual abligsgons.
INSPECTOR GENERAL (COOK COUNTY CODE, CHAPTER 34, SECTION 34 174snd Section 34 256)
The Applicant has not willfully failed to cooperate in an investigation by the Cook County Inde pendent Inspectar General
or ta report ts the Independent Inspector General sny and all infonnagon concerning conduct which they lanaw tc involve
corruption, ar other criminal ecfhdty, by another county employee or oNcial, which concerns his or her aNce ofemploymsnl or County related tmnsection.
Ths Applicant has reported dirscgy snd without any undue delay eny suspealed ar Imcwn fraudulent aagvlty In thsCounty's Prccwsmsnt process to the ONce of ths Cask County Inspedar GeneraL
CAMPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECfION 24BD)
THE APPLICANT CERTIFIES THAT: It has nmd and shag comply, with the Gook County's Ordinance concsining
campaign canhiMans, which is crxfNed at Chapter 2, Division 2, Subdivision II, Sscgan 585, and can be read in Ihr
ange at www.munlcads.corn.
GIFT BAN, (COOK COUNTY CODE, CHAPTER 2, SECTION 2474)
THE APPUCANf CERTIFIES THAT: It has read and shall camply with the Cook County's Ordinance concerningreceiving and salicigng gilts and favors, which is codified at Chapter 2, Division 2, Subrgvision II, Section 574, and can bereed In its engrsty at www. munkxrda corn.
UVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34-160;
Llnless expwssly waived by the Cook County Bomd af Commissioners, the Code requims Dist a living wage must be paid
to individuals empkryed by s~which hss a thainty Contract and by eg subcontractors of such Contractor under aCounty Coatrack throughout ths dursfion of such County Contract The amount of such living wage is annually by thsChief Flnsndsl ONcer of ths County, and shall bs posted on the Chief Pracuremsnt ONcm's website.
The term "Gcnhsct" as used in Secgon 4, I, of this EDS, specBcally atdudes contracts with the following:
1) Nutbar Profit Organizsfians (defined as a cmporation having tax exempt status under Section 601(G)(3)af theUngsd State Internal Revenue Code and maognized under the ggnois State nct-for -profit law);
2) Community Development Block Grants;
3) Cook County Warks Department;
4) Shedlfs Wark Altemaths Program; snd
6) Department of Cormrslan inmates.
EDS-2 $2016
CONTRACT ND, 11-63-185B
SECTION 3
REQUIRED DISCLOSURES
1. DISCLOSURE OF LOBBYISTCONTACTS
List ag persons that have made lobbying aonlacts on your behalf with respect to this contract:
Name
2. LOCAL BUSINESS PREFERENCE STATEMENT(CODE, CHAPTER84, SECTION 84-238)
Lacer Ous/ness means a Person, Indudlng a foreign corporagon authorized to bunsact business in Nllnols, having a bona fidesstabfshmsnt located wNhln the County at which it is transacgng business an Nre date when a Bid is submitted to the County,and which employs Nw majority of its regular, full-time work force within the County. A Joint Vsntum shag consgtuta a LocalBusiness if one or more Persons that qualify as a "Local Business" hold intsresh totaling over 50 percent in the Jokrt Venture,even if the Joint Venkvs daes not, at the time of the Bid submiNal, have such a bona fide establishment within ths couniy,
a) is Appgcant a "Local Business" as defined shaver
Yss: . Na:
b) If yes, list business addresses within Cook County:
+3~ /4~4,'C~( eda2
c) Doss Applicant employ the majoriiy of Its mgular fug-time woddarce within Cook County7
No:
3. THE CHILD SUPPORT ENFORCEMENT ORDINANCE (CODE, CHAPTER 34, SECIION 34-1T2)
Every Applicant for a County Privilege shag be in full compliance with any child support onier befam such Applicant is entitled toreceive or renew a Ccunly Privilege. When delinquent chgd support exists, lhs Caunty shall nol issue or renew any CountyPdvgege, and may mvcke any County Prlvgsge.
AN Applicants are required to review Nm Cook County AISdavlt of Child Srqrpok Obligagons sNachsd to this EDB (EDS4)and camplsts the Allidsvit, based on the instrucgons in the Affidavit.
EDB-3 NI2015
CONTRACT NO 11-5S-186B
rk REAL ESTATE OWNERSHIP DISCLOSURES.
The Applicant must indsuds by checking gre appropriate provision below and pmvidlng ag rsquimd information that rdttrer.
a) The following ls a complete list of all reel sslals owned by gw Applicant in Cook County:
PERMANENT INDEX NUMBER(S): k4~
(ATTACH SHEET IF NECESSARY TO I)STADDITIONAL INDEXNUMBERS)
b) ~The Applicant owns no real estate In Cook County.
5. EXCEPTIONS TO CERTIFICATIONS OR DISCLOSURES.
If the Applicant is unsbls to csrgfy to any of grs CertiTications or any other statements contained in thar EDS and not mrplained
elsewhere in this EDS, the Applicant must rerplain belovr.
If Ihe letters, "NA", the wmd "None" or 'No Response" appears above, or if the space is left blank, it will be concluskrely presumedtlmt gts Applkmnt csrfged in all Cerglicsgons and other~coniained in gris EDS.
ar201 5
CONTRACT NO tt-531650
Zip Code. Ie 07 dEmaik g / +wrruJ fs)W c~
COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT
The Cook County Code of Ordinances ([2-610 ei eeq.) requires gmt any Applicant for any County Acgon must disclose Infarmegonooncsming ownership Intwssls In the ApplkmnL This Disclosum of Ownership Interest Statement must bs compkrted with ellinformation curmnt ea of lhe date this Statement Is signed. Furthermore, this Statement inust be kept current, by filing an amendedStatement, until Such time as the County Board or County Agency shall take adkm on the spplicatkm. The information contained inthis Statement will be msinkttned in a database and made available for public viewing.
if you am asked to list names, but there am no applicable names to list, ycu must state NONE. An incomplete Statement wig bereturned and any action regarding this contract will be delayed. A failure to tully camply with the ordinance mey result in the sdlontaken by ths County Board or County Agency being voided.
"Apso/mt'eans any EnNy or parson making an application to ths County for eny County Action."County Acgon" mesne any adlon by s County Agency, e County Oepadmsnt, or gw County Basal regarding sn ordinance orordinance amendmsnt, a County Board sppnwal, or other County agency appmval, with respect to contracts, leases. or sale orpurchase of real esktte."person"Endt)e or "Legal Entity" mesne a sour propdslwsMp, aatpotstlon, psrtnemhip, assodstion, business ttust. estate, hro or
more persons having s joint or common internet, trustee of a land trust, other commerdal or legal entity or any beneficiary orbensgdmiss thereof.
This Disolosure of Ownership Interest Statement must bs submitted by:1.An Applicant far County Adkrn and
2. A Person that holds stock or a beneficial internet in the Applicant and ls listed on the Applicant's statement (a "Holder" ) must file aStatement end complete $1 only under Ownsmhip Interest Dedaration.
please print or type respanses clearly and legibly. Add additional pages if needed, being careful tc idengfy each poAion of the form towhich each additional page refers.
This Nstement ls being made by the [ g Applicant or [ ]Stock/Beneficial Interest Holder
This Statement ls an: [~]Odilfinsl Statement or I ]Amended Statement
Idsngfylng Information:
Name Woora/ (f8'' 4 y I/d 4"~Area ~ ~nM-0/B/A: 4 & ov 7' 7c- 6'w WA FEINNO.: Z f —WC/0 9 7~~Stmet Address: TL2 7ctlr. 4* / - 4 . shah.: ~cLy N .C7//ilrmr ~e// v N, t f/at> ~/ wx/r-
Partnership
gauds
Cook County Business Registration Number(Sole Proprietor, Joint Ventura Partnership)
Corporate File Number (Ifapplicable),'ohn
of Legal Entity:
[ [ Sole Proprietor [ ][ ] Business Trust [ ]
[ ] Other (describe)
Corporahon
[ ] Association
[ ] Trustee of Land Trust
( 1 Joint Venture
Ownership Interest Oeclaration:
1. List the name(s), address, and percent ownership of each Persan having a legal ar censfrdat Interest (indudkrgownership) of more than five percent (5%) In ths Applicant/Holder.
Name Address Percentage Interest in
Applicant/Holder
PrcJiw e- r f M tn// gy ~8 ~~A.]f'i''rgr"~)Fd"F C'o2XF~evt. dcv .Ate . 22 rob'rex
AiDb %+Ha 2 oO eJr'.4 r/ear 8'orae JE[j r '/oleo+.37 r apvn/
'h2/rPnsm
> )2'n
6/201 5
2. If the interest of any Person listed in (1) above is held as an agent or agents,and address of gw pdincipal on whose behalf the interest is held,
Name cfAgent/Noriwrse Name of Prindpsl
PJZI/'T(L Is the Applicant constructively conbclled ljy another person or Legal Enmy?
If yes, state grs name, address and percentage of bsnellcial Interest of suchsuch control is being or may bs exwclssd.
CONTRACT NO. 11-53-155B
or s nomirme or nominees, list the name
Prinmpal's Address
( ]Tee ( Q]No
person, and the relationship under which
Name Address Penxrntage ofBeneficial intmsst
Rslsfionshlp
4'r/'1I''77
Corpomts Offleam, Members and Partners Information:
For all corporations. list the names, addresses, and terms for ell corporate ofticers. For ell limited liability compankrs, list thsnames, addresses fcr all members. For ed parlnershlps and]obit ventures, ibt the names, addnmsss, fm each pmtnsr cr jointventure.
Nsms Address Title (spsmfy tige cf Tenn of O%ceOflice, or whsgrsr manageror parlnerljointvsnture) ~ ~ g (]//di/~/P
Ckfaf ~ J '/I(M>'px', /~/ Off Bf E~ A~ 4krpJ C. ~rrxwrem 8/J~/W,+rr~~.'c Iv crw~~~Q ~~9~x~m/4. /rrcr~5~7,%< . No eOrcrr w/+~~I'&I~Deolrsadon (check the applioabie box}:
[ I state under oath that the Applicant hss withheld no disclosure as to ownership Interest in the Applicant nor reservedany informafion, dais or plan as to the intended use or purpose for which ths Applicant'seeks County Bomd or otherCounty Agency action.
[g] I stats under oath that the Holder has withheld no disdosure as to ownership interest nor reserved sny informationrequired to be disolosed,
Name (BIiorb]ed pp cl]t]jr Representative (please print or type)
.5'~V)LA8' 8~C,C
SubscnTXBLto and swpm before mp.this rfx r day of~/', 20
~Idle Signature
EDS-7
Title
A'~~Date
Fdic}) XW~9"M dr]ons Number
My commission expires: ~~~/"OFFICIAL
SEAL'TEYENJ. M]LLEANota y 8](bTARY PUBLIC, STATE OF ILLINOIS
My Commission Expires Sf'](r'jj}]y
CONTRACT NO. 11-53-1055
CX)OK COUNTY BOARD OF ETIBCS69 W. WASHINGTON STREET, SU1TE 3040
CHICAGO, ILLINOIS 60602312/603-4304 Oifice 3 12/603-9988 Fsx
FAMILIAL RELATIONSHIP DISCLOSURE PROVISION
Neuotbm Disclosure Reauirementr
Doing s sigmficsnt amount of business with the County reqsires that you disclose to the Board of Ethics the ex'wem of anyihmilial relatlonsldps with sny County employee or any person holding elective office in the State of Illinois, the County, or iu
any nmaicipality wlbin the County. Ibe Ethics Ordinance defines a signigcsnt amount of business for the purpose of thisdisclosure requirement as more than $25,000 in aggregate Couaty leases, connucts, purchases or sales in any calendar year.
Ifyou are unsure ofwhether the business you do with the County or a County agency will cross ibis threshold, err on the sideof caution by comphatug the attached gauilial disclosure form because, among other potsnthl penalties, any person Lundgufity of failing to make a required disclosure or knowingly filing a fblse, misleading, or incomplete disclosure will berobhibdted fiom doing asy business with the County for a period of three yarns. The required disclosure shoukl be Sled withthe Bead ofEthics by January 1 of each calendar year in which you are dobtg business with the County and syua with eachbid/proposai/quotation to do busines's wbh Cook County. The Board of Ethics may assess slate filing fee of$100per day sitarsn initial 304ay grace period,
The pemon that is domg business with tbe County must dtschne his ot hsr familial relationahip, If the person on the Countylease or nmtract or pacbasing Sum or selliug to the County is a business cndqi, then the business endty must disclose thefsmigd relationships ofthe Indivtduab who sre and, during the year prior to doing business with the County, were:
~ its board ofdhectcrs,~ its officers,~ its employees cr independent contractors responsible for the general administration ofthe entity,~ its agents authodsed to execute documrmts on behalf of the sntky, snd~ its employees who directly engage cr engaged in doing work with the County on behalf ofthe endty,
Do not hesitate to contact the Board of Bhics at {312)603-4304 for assistance in determining the scope of sny requiredSumlial relationship disclosure.
Additbmal Definitlous:
nFuwiliul relationship" means a person wbo is a spouse, domestic partner or civil union partner of a County employee or State,County or municipal otficisl, or any person who is reland to such an employee or official, whether by blood, marriage oradopunc, as a:
Cl Psmnt0 Child0 BrotherCl Shter0 Amn0 UndeCl NieceCl Nephew
CI Grandparent0 Grandchild0 Father tu-law0 Mother-in-law0 Scn-in-lsw0 Daughter-in-hrw0 Brother-in-Iaw0 Sister-ln-law
0 Stepguher0 StepmotherCl Stepsonl3 Stepdaughter0 Stepbrodux0 Stepsister0 Half-brother0 Half-sister
Bi2015
05-10-'16 15:03 FR(gt- T&82 F0002/0003 F-1 66
COOK COUIuTY BOIkBD OF RTEECSPAMKIIIL BRLItTIORSEIP DBICLOSUBR FORM
CONTRACT NO 11-es qa>>
pBBstBIBGttiU oR sRREING To Go lmnennn wlTE TNS coUNTY
.n ccccc nc.c,e etSe .Ster 7e~ Ce'c wne eec.c~ V'.S~ ntnee. Sc.et+rang~
Phone uumbtr nfPweoo Doiag ssshnm wldr the coenty. 004N M 0 /d /tt .BmsilsdthenofpersrnDoiaggusinesswilntbeCtnnUc S 4 7~~ellt/ lk Ncu/ ~ COm
lf Perros Dtdng Business wgb Sw County is s Badsms Banty, provide the earns, tide md contact, hticnmathn nn Iheindividual qenp~ dds lealeenp en behalf of the Parsee Doing Sorifstsf tfiih tbe CeougcI~cc Pfker '~ . PW 0 C'rrCSeta,~
r e
/> o f I .c-~ s I~ / d
DRSC I!PT%0ffOS'lmf NRSS WffE TBIICOUNTYhppaet odgtrtonri yttgtn es Iteednf end for eecft ceanh !terse, contnan yntwlnoe o safe wntgin enticerctstttttiedtl<f I'lie cnlendet'yore@ rhrs sysohunte (or She~ tndsnlfatyset (ftgtdotnt4l it IIIed'ean Jonncsy I), rrtsnri(h
Tho lsatC amah ac, ostrnetu nendne, pmebsse order naaber, retytttn thr proposal nraobte aatyur request ga.qualigcrgm mmtbtu arsoeisted wnh the business yeu src doiag or setktsg to do whb the county:
74r~ // -WS- /SS+The sgsngtm dollar vates ofSnbosinsss y'ou em drdag or sesktug te do w&h the county: s
Thc usmc, use aud contact iafcsmstioa!br the cosuty o!ltlaI(s) m~a) involved ia asgonsnng the businessytnt sre dolag or ~e'o do wgh tbe County: I tt 7Z) T'4 4 ~ to
Is<A'I~My.iiower-/tel~ .6 -M'S 7.The esne, gde ntd cantata~srr the come olgelal(s) or smployee(@avoivelt Bmsnegmg the burhn4nysu Stc dang er retddng mc ds Whb SW Ceuhty: ctr WI C ~Ra et -'.
. MW( 72.S)f&-Erg g>
DISCIdBRRIBOIy FABIEBhLERLSITTONRfttyg WITE'COUNTY RhdPLOTRRSOB STSkiK~Out IsiriNICEtnL~OtrnlCttsLS
check tits brrr rhss sfytste Sanfyves hh tvdered hdkttnotnm whww ttcctted
0 The PersonDoiag Buriaem vdth the County ls aa tndtvtdnet end them is no femigel relationship between thisiudlvlderd ead any cook Couasy anpioyco or sny paeon holding elective oBIoe in un grate of Illinois, Cook county,or any munbdpsllly wlthke Cook Cranny,
The PertsnDohtg Business whh tho Causey is a boehmes sathy sad there is na Suuglel relationship lcttrom rny'ababsr ofdds trushtess aatgy's boast of~44!5aenl pwsoae tmptnedble Sa gseerel edmhdsinulee of the
business surgy. agents Iuuherimd to etrsoute doeuramm onbehal(oflhe buslawa eaSy m employees dhnalyengegedht sonneeluat rank wgh dm County on Melt of the bushum cngiy, aed aay Cook Couoty wnyhyee or eaypwoonboldiag elective algae ht Ihe State ofUlineis, Cook Coaaty, w any tamdchngsy wlddu Cook Coemy.
EDS4I
CONTRACT NO. 11-53-1858
COOK COUNTY BOARD OF ETHICSFAMILIAL RELATIONSHIP DISCLOSURE FORM
C The Person Doing Business withtbe County h sa individual sud there ts a familial rdagonshtp between thisindividual snd st least nne Cook County employee aad/or a person or persons holding elective office in the State ofIllinois, Cook County, snd/or say municipality widun Cook County. The familial rebtttanshtps are as follows:
Nsrse of Individual Dong Name ofRdsted County Title sud Position ofRelatedBusisess with the Coesty Employee or Sate, County or County Employee er State, County
Municipsl Bected Ofllcisi or Municipal Elecsd Oflicial
Nature of Faruilialgdstion ship
IJIE/IRIFTIfmors space ts needed attach an additional sheet followiug the above formu
y
The Person Dciag Business whh the County is abtudness entity mul there is s fern Igni rdationship between at leastone member ofthis business sulky's board of hectltnb ofgcers, penens responsible Srr general adnunistranon of thebusiness endty, agents authorize tu mrecute documaats on behalf oftba business entity snd/or employees directlyengaged in coatractual work whh the County on bebtdf of tbo businem entity, on the une band, and at least one CookCounty employee and/or a person hoidhg elective oggce in the State ofIllinois, Cook Cotmty, and/or snymunicipality wlthh Cook County, on the other. The familial rehtisuships ave as foguws:
Name af Member ofBondofDirector for BusisuaEntity Doing Business with
the County
Name of gdsted County Title snd Positiori ofRelatedEmployee or State, Couuty or County Employee or Sate, CountyMunicipal Bested Oflicial or Municipal Elecsd Offici
Niuure ofFsuulielRelsticnsbip
/ /fName of Oiflcer for Bus Name of Related County,EuthyDohggustuessvdtb EmployeeorStste, County ortbe Coiilriy Municipal Bected Oflicisl
Title sud Position ofRelatedComty Employee or Sate, Countyor Municipal Elecaxl Officisl
Nsturc of'Familisl
Rdsdcusbttr'~/
f
EDS-10 N2015
CONTRACT NO. 11Q3-tSBB
Name of Person Iteyeublefor the GeneralAdmimstration of the
Business Entity DoingBusinnu with the Cesety
Name ofMated County Title and Position ofRelated Nature of Familial
Employee or Sate, County or County Employee or State, County RelationshipMunicipal Elected Offlctat or Municipal Blacad Offfcial
Name ofAgent Authorized Name ofRelated Couaty Title anri Positiaa ofRelated Netmu ofFamilial
to Execute Documents fm Employee or State, County or County Employee or State, County Rctmtonship
Business Entity Doing Municipal Etectcri Official or Municipal Blectsri OfffcialBushuss with the Ccssty
yy zi
Name ofEmployeeBusiness Batity Dis!'ctly
Engsgeri in Doing Bmlnesswith the County
Name ofRelarsri County Title and Position ofRelated Nstme ofFamiTiel
Employcc or State, County or County Employee or Sate, County RelationshipMutricipdBlectal Oilidial 'r Municipal glectnt Official
Ifmore space is needed, attach an additional sheet fogowing the above format.
CATIO¹ To tba b f wl the 'i I fest o my kno edge, mforma on I have provided on this dmc osure orm ts accurate andc,lac o or incomplete disclosure is punishable by law, inclutgng but not lhnited to fmessnd nt.
Signatme ofRgipienf)
VSUBMIT COMPLETED FORM TO:
A~9Da /
Cook Cotmty Board ofEthics69 West Washington Street, Suite 3040, Chicago, Illinois 60602Office (312)603%304—Pmt (312) 603-9988CookCounty. Bhics@cookcountyilgov
Spomm, dcmesdc pmtaar, civil union partner or parent, clued, sibling, aunt, uncle, niece, nephew, grandparent or gnmdchildby blood. marriage (Ia in laws and step relations) or adoption.
CONTRACT hiO, 11-63 18SB
SECTION 4
COOK COUNTY AFFIDAVIT FOR WAGE THEFT ORDINANCE
iiEffscffve htay1, 2015, sveqr Person, /nc/udino dubrusndn/Cwnwu seeking s Contract with Cook County must comply with ths Cook County Wage ThsffQrdlinance sst forth in Chapter 34, Arffds IV, Berdon 179. Any Pmuou/Substantial Owner, who fsffs to comply with Cook County Vusge Theff pidtnumwrosy inquest that the Chief pmourement Officer grant a redudicn or waiver in accordance wffh Section 34-179(d).
"Gcnhact" means any wnturn document tc make Procuremerun by or on behsit of Gook County.
"pervoi/'esne sny individual, corporation, pnrlnership, Joint Venture, tnmt, asscdetlcn, thnffsd ffsbillly company, sole prcprlelomhip or other legal enuty
rpru Cenvnenf'eana Obtaining Sup pffee, equipment, geode, Or Seiduee Of any kind.
"8uhntendsr Owner" means any person or pwsons who own or hold s twenty. five percent (25%) cr mors percentage of Interest in any business enfftyseeking a County Prlvffece, 'mduding those shwehoklers, general or Snked psrtnsm, benefmiedes nnd prindpsle; except where a business enuty m snindividual or sole pro pffetomhp, Substantial Owner means that individual or sole proprietor
Aa pemone/substantial Ovnmm are wqulmd to complete this sfftusvlt and comply with ffw cook County wage Theit ordinance bslore sny Gonuact hswarded. glgnaturs of thin form conetltulen a ceNltcaffon ths Infonnaffon provided below is correct snd complete, end that ths individual(s) signing this fcrnihas/have personal knowlsdce of such Infcrmeffon.
I. Contract Information:
Contract Number; /'/' .Cq —/'A~A'ounty
Using Agency(requesting Procurement): r ( A.sr~.'Y P'r
II. Pemon/Substantial Owrier Imformstlonr
Person (Ccrpomte EnNy Name): XYcr f rr 6V E / W l$ .~ct,+H~~Substantial Owner Complete Name: r C ye~& J, AVE/-PFEIhw 2 t~ — WG rf F~
rDate of Birth: E-mall address: A. / 7 ~v urrr(-W cecil c~
/Street Addrarm: A AI 7'F Gur. 8 fCity: Ecnn Suds: ~C Ztp;Qc25 4 7
Home Phoria: ~ "7AFW —fe fp Mf Drivm'a License Nc:
III. Compliance with Wage Laws:
Wrlhin the past five years has the Person/Substantial Owner, in any judkdal or administmtive proceeding, been convicted of,entered a plea, made an admission of guilt cr llebfflty, cr had an admlnlstragve finding made for committing a repeated ur wfflful
violation of any of the following laws:
ii/inois Wage Peymenf nnd Codsct/on Act, 820/LCS 118/1 etseq., YES r NO
///inc/s Minimum Wage Act, 820/LCS 105/1 etseq., YES ~NO
////nu/s Wodrer Adjustment nnd Retraining No//iicetion Act, 820/LCS 85/1 et nsq., YES NO
Emp/oyse Clessiffoaffon Act, 820/LCS fffdrf e/eeq., YES ANFair Labor Standards Acl of 1938, 29 l/ SC. 201, eteeq., YESo 0
Any compemb/estate statuie orraguie5on o/any state, which governs the payment of wages YES or 0If the Person/Substanffal Owner answered "Yea" to any of gm queugons ebrnm, It ls Inellgtbie to enter Into a Contract with CookCounty, but cen request a reduction or waiver under Section IV.
EDS-12 8/201 6
CONTRACT NO. 11-53 155@
IV. Request for Waiver or Reduction
If PerscnlSvbslantlal Owner answend "Yes" to sny of the questions above, lt may inquest a reduction or waiver lnaccordanoe with Section 34-179(d), provided that the request for reducbon cf waiver is made on ths basis of one or
ng acgons that have taken place:
a bona lids change in ownership or Control of the ineligible Psmon or Substantial Owner
hes been taken against the inrgvtduat(s) rssprmstbte for the acts giving rise to the vtolagon
es been talma to pmvent a neunence of the acts giving nss to gm disqualigcagon or default
Other factum gmt tire Person or Substantial Owner believe are'relewmt.YES or NO
The PsmonfgubstsnUst Owner must submit documentation to suoood the basis of Its mouest for a rsducffon or waiver. TheCMef Procumment OScer msen es the dont to make
eddilkealinouiri�a
snd rsouest additional documentagon.
V. AfgrmationThe Pemon/Sub al wn s aU s ls contained ki the
Affidavit
are
tru, accurate and complete.
Signature: P. l)'l<1 3'ats: W~v'. M /4,r
NameotPersonslgning(priIi0: clMsnRe~- Ifj * Pfrrdjd fr Tlge:
ubscribed snd swo o.bef me this W day of Astir ,20 frZ,
x ~7$%dj Public Signature 'otary Seat
Noter The above infonnsdon ls subject to vsrigrmffon prhv to the awsnt of the Contmct. I "IPFICIAI. SEAL"STEVEN J, MILLER
NOTARY PUBLIC, STATE OF ILLINOISUty Commission Expires 3/30/201 8,
Uf2015
CONTRACT NO. 11-63-1SUB
SECTION 5
CONTRACT AND EDS EXECVTION PAGEPLEASE EXECUTE THREE ORIISINAL COPIES
The Appiicant hereby oerhiiss snd warrants that sil of the slatsments, ceriificalions and representations set forth in this EDS are
true, complete and ccrrecL'hat the Applicant is in full compliance snd will congnue to be in compliance throughout the term of the
Contmct or Couniy Privihgs issued to the Applicant with afi the policies and requimments set forth in this EDS; and that afi factsand irdbrmafion provided by the Applicant in this EDS are ime, complete and coriecL The Applicant agrees to inform gre CNsfprocurement Ofticer in wrifing if any of such statements, cemficsfions, rspresenlafions, facts or Info/mellon becomes or is found tobs untrue, Incomplete or incorrect during the term of the Contract or County Privilege,
Execution by Corpo ati
rr~/rex e~6 m w.QXIILZCorporahon's Name P//~PE 4e, 4 p,e fi„w /c/,4. President's Pont/ Aa)e)kd hlgnatur) )C7dySAPY —
V Wdy'"
w 'P ~n> a~E c-c~Tele h EmMI
Y".>md'ecretary
Signature Date
Execution by LLC
LLC Name *Member/Manager Printed Name and Signature
Date Telephone and Email
Execution by Partnership/Joint Ventum
Partnership/Joint Ventum Name *Partner/Joint Venturer Printed Name and Signature
Date 7/I Telephone and Email
Execution by Sole Proprietorship
Printed Name and Signature
Teiephone Email
Subscri and sworn to before me thisday of ~,20 /k.
/
Notary Public Slgnrtfi/re
My commission expires: 9/Z4PK~~E
Notary Seal < STEVEN J, MILl ttfNOTARY PUBLIC'TATE OF ILLINOIS t
If the operating agresmsnt, partnership agreement or governing documents require( sx@%QSRtSA%81@PI944%@OS gmanagers, partners, or taint venturers, please complete and execute additional Contract and fDS Execution Pages.
EDS-16 &/2016
AC@)RD"WOODS-2 QP )D; BL
CERTIFICATE OF LIABILITY INSURANCE
INSURER(8) AFFQRQ)HG CQYERAG E
BMURBRX: United Fire 8 Casua)ty Companymsuhch 8:Hanover Insurance CompanyINSURER C:INSURER O:
HA)C d
1302122292The Woodstock & Wallstraet
Corpdba Automotive Tech Center435 Madison StreetDak Park, IL 60302
)NBUREO
)HBURER E:)MBURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER/ODINDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMN'6 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ECBR XUUL vutln FOLIC F POLICY EXFLlR 1YFE OF (NBURRHCE ivan Wlic POLICY NUMBER IMM)QQ)YYYY) NIM)co)YVYV) LIMITS
A X COMMERCIAL GENERAL Lido)Lily EACH OCCURRENCE ICt Mb)SMnQE X QQQUR B0431624 05/O'U2016 05/01/20'll pptbBSESIE
MED Exp lnny one person>
PERBQHnt b AQV )H JURY 8
1,000,000100,000
5,0001,000,0002,000,0002,000,000
GENERAL hG GREG Al'GEH'L nGGREGAYE LIMIT nppt)EB PER
POLICY ~ JEQY ~ LQC~ PRO.
OTHER
AUTOMOBILE Ults)UIY
A X ANY AUToALL OWNED SCHEDULEDAUTOS AUTOS
v HQH-QWHEQX HIRED AUTOS X AUTOS
)( UMBRELLA Lips ~X QCCUR
EXCESS Linei ) Ckll)MB MADE
) OED I X IREIEHIIQHFWQ RHERB CQMPEHBAT) ON
AHQ EMPLOYERS'Ltbs)L)ly YIHB ANY PRQPR)ETQRIPAR)HER)EXECUT)VE
QFF)QER/MEMBER EXQLUQEDY ~ H)A(Mandstoty In HH)ifyes descnbe underDESCRIPTION OF QPERAT)QHS below
A Garegekeepers
PRQOUCYE CQMPIQP AGG 1Emp Ben. 8CQMOHEU SINGLE L)M)1IEa accidonti
05/01/2016 05/01/2017 BQOLYWJURYIPerpetson) IBQQ)LY )HJUI)Y IPer acctdent)
PROPERTY DAMAGEJper accident)
8
1,000,0001,000,000
60431024
1,000,0001,000,000
EACH OCCURRENCE
05/01/201S 05/01/2017 AGGREGAlE60431024
$
~x";05/01/2016 05/01/201 7 E L EXQH ACCIQEHT $
E L Q)BEAEE EA EMPLOYEE 8
E L O)BEI)EE - PQLIC'i LIMIT I05/91/2016 05/01/2017 Limit
Ded
IN2CA617151-01 t,oao,ooa1,000,0001,000,000
Saa,aaa500
60431624
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THISCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY ASIEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOES NDT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHDRIEEDREPRESENTAllVE OR PRODUCER, AND THE CERllFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INBURED, the policy(les) must be endorsed, If SUBROGATION IS WAIVED, sub)eel tothe terms Bnd conditions of the poncy, cs)'tain pollclss msy I'BIIUlre En endo)'BemenL A slatemsilt on this QBNNcate does )lot confer rights to thecertificate holder In Beu cf such endorsement(s).
PRODUCER west Total Insurance ServiceTotal Insurance Services, Inc. PHQHE FAXPaul Bondar 6 Edc Leader lAIQ. Ho Extt: 947 205-1777 inic. Hoh 847-205-19193175 Commercial Ave ROQREBB:Northbrook, IL 60S62Eric Leader
QEBCR)PY)QH OF CPERnl)QHS I LQCAY)QHB I VEMCLEB IACQRQ tet, Add)i)anat Remarks Schedule, may be attached if mors sPace Is requited)
CERTIFICATE HOLDER
CooK County119N. Clark StreetChicago, IL 60602
CANCELLATION
COOK005SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORETIIE EXPIRATION BATS THE)laos, Nollca WILL BE DSL)YSRBD )NACCORDANCE WITH THE POLICY PROVISIONS.
ADO RD 25 (2014/01)
O 1988-2D14 ACE)RD CORPORATION. AS rights reserved.The ACORD name Bnd logo are registered marks of ACQRD