Contract No. 12-45-395Vendor Name: Tyco integrated Security

AMENDIylENT NO. 4

This Amendment modifies Contract No. 12-45-395, for Alarm System Monitoring And Annual Maintenance

for the Cook County Treasurer's Office, Department of Revenue, and Clerk of the Circuit Court, by and

between the County of Cook, illinois, herein referred to as "County" and Tyco Integrated Security, authorized

to do business in the State of illinois hereinafter referred to as "Contractor":

RECITALS

Whereas, the County and Contractor have entered into a Contract approved by the Chief Procurement

Officer on April 30, 2013, (hereinafter referred to as the "Contract" ), wherein the Contractor is to provide

Alarm System Monitoring And Annual Maintenance (hereinafter referred to as the "Services" ) from January

1, 2013 through December 31, 2013 with two (2) one-year renewal options, in an amount not to exceed

$72,463.78; and

Whereas, Amendment No. 1 was authorized by the County Board on May 21, 2014 for a renewal from

January 1, 2014 through December 31, 2014 and an increase in the amount of $91,890.75;and

Whereas, Amendment No. 2 was executed by the Chief Procurement Officer on September 4, 2014 for an

increase in the amount of $534.00 for additional monitoring and maintenance services at the Bddgeview

Courthouse; and

Whereas, Amendment No. 3 was authorized by the County Board on April 29, 2015 for a renewal from

January 1, 2015 through December 31, 2015 and an increase in the amount of $93,683.51;and

Whereas, the Contract will expire December 31, 2015 and the agreed upon Services are still required; and

Whereas, an extension is desired for the continuation of Services; and

Whereas, an increase in the amount of $92,604.96 is required for the continuation of Services; and

Whereas, the County and Contractor desire to extend the Contract for twelve (12) months beginning on

January 1, 2016 through December 31, 2016.

Now therefore, in consideration of mutual covenants contained herein, it is agreed by and between the

parties to amend the Contract as follows:

1. The Contract is extended through December 31, 2016.

2. The Contract is increased by $92,604.96 and the Total Contract Amount is revised to $351,177.00.

3. GC-06, Payment is deleted in its entirety and is revised as follows:

Rev I/1/I 5

Contract No. 12-45-395Vendor Name: Tyco Integrated Security

"All invoices submitted by the Consultant shall be in accordance with the cost provisions contained in

the Agreement and shall contain a detailed description of the Deliverables, including the quantity of theDeliverables, for which payment is requested. All invoices for services shall include itemized entriesindicating the date or time period in which the services were provided, the amount of time spentperforming the services, and a detailed description of the services provided during the period of theinvoice. All invoices shall reflect the amounts invoiced by and the amounts paid to the Consultant as ofthe date of the invoice. Invoices for new charges shall not include "past due" amounts, if any, whichamounts must be set forth on a separate invoice. Consultant shall not be entitled to invoice the Countyfor any late fees or other penalties.

In accordance with Section 34-177 of the Cook County Procurement Code, the County shall have aright to set off and subtract from any invoice(s) or Contract price, a sum equal to any fines andpenalties, including interest, for any tax or fee delinquency and any debt or Obligation owed by theConsultant to the County.

The Consultant 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 correct. The Consultant acknowledges that by submitfing the invoices, it certifiesthat it has delivered the Deliverables, i,e., the goods, supplies, services or equipment set forth in theAgreement to the Using Agency, or that it has properly performed the services set forth in theAgreement. The invoice must also reflect the dates and amount of time expended in the provision ofservices under the Agreement. The Consultant acknowledges that any inaccurate statements ornegligent or intentional misrepresentations in the invoices shall result in the County exercising all

remedies available to it in law and equity including, but not limited to, a delay in payment or non-payment to the Consultant, and reporting the matter to the Cook County Office of the IndependentInspector General.

When a Consultant receives any payment from the County for any supplies, equipment, goods, orservices, it has provided to the County pursuant to its Agreement, the Consultant must make paymentto its Subcontractors within 15 days after receipt of payment from the County, provided that suchSubcontractor has satisfactorily provided the supplies, equipment, goods or services in accordance with

the Contract and provided the Consultant with all of the documents and information required of theConsultant The Consultant may delay or postpone payment to a Subcontractor when theSubcontractor's supplies, equipment goods, or services do not comply with the requirements of theContract, the Consultant is acting in good faith, and not in retaliation for a Subcontractor exercisinglegal or contractual rights."

4. Attachment No. 1 - Pricing Proposal forms are incorporated and made a part of this Contract.

5. Attachment No, 2- Identification of Subcontractor/Supplier/Subconsultant, MBE/WBE Utilization

Plan, and Economic Disclosures Statement forms incorporated and made a part of this Contract.

6. All other terms and conditions remain as stated in the Contract.

Rev orna

Contract No. 1245&5Vendor Name: Tyco Integrated Security

In witness whereof, the County and Contractor have caused this Amendment No. 4 to be executed on the

date and year last written below.

County of Cook, illinois

Chief Procurement Officer

Date: 9 Jttf/tt: ZOIC'ypeor print name

EMn~~Title

Date

Rev //1//5

Contract No. 12-45-395Vendor Name: Tyco Integrated Security

ATTACHMENT NO. 1

PRICING PROPOSAL

R ev 1/1 ll 5

,, Ty00:-'/AT., 45+ Stog<Xity:~jg<kjP'5k~<'j5'gv

V$':,".:-.;ag,pseia, 5ttfjta,.i .<.2 e t 5 5 < 2 1 e54 2 r 5 1 1 V 1 e t 5 < 0

Wove Jnber 4, 2015

QUOTE

Tyeelktesrared security

2050 Seelft:Drive

Dak gyook, IL N525blreet 550-645 6652

Joyce M. Steele, JVIBA

Director of Operafions

Cook C<gunty Daf<krRnent of Revenue

118 N. Cfgrl< St,<Rm 2160Chica'g'o„ lt. '69602

RE: County of. cedk, Department of Reyehue

TyCo IS A„ccoknt 131-18506

Dear Joyce,:,

The proposed servjce retes for 2016are>

$12,900.57 Jan 1, 2016-Dec 31, 2016

This includes existing protection and sekvicegfor Intrusion De'tectjph (bugg'ler'- alaittr); Accdss

control, a'pd video surveillance,

P'lease let m<r I<now Jf you require a<jditloeaj'Infer<net!onj Jgrlhaykeny questl'ons,'T%anlfyou,

'in

carel'achel.

Sab'ado

630-898-2705Cornmerclel Account Ekeputive

'Tyco Integrated Security

November 4, 2015

Paul Kawa

Director of Human ResourcesOIRce of the Cook County Treasurer118N. Clark St.,Suite 212Chicago, IL:60602

Tyco integrated Security2010 Swift Drfv'e

Oak Brook, IL60525Direct 680-.645-6652

RE: Cook County Treasurer's Oflice

Tyco IS Actount 131-39920

Dear Paul:

'Iha following seneca rates are proposed from January 1,2016 through December 31,2016

This amount indudes a deduction of 4360.10/year from 2015 rate for the removal. of Intrusion Detection,(burgle r) devices on the 2""floor south ofgces (refemnce your servtc'e request service to remove fromthe va'cated space); As iniiormation, the current rafa through Decsinbi,r.31, 2015 is 561,326.10,

$60,966.00 Jan 1,2016-Dec 31,2016

This Includes edsting protection and services for Intrusion Detection, Access control.(l/c), and videoSurvegla neo.

Please let me know if you require additional information, or have any questions. We appreciate theopportunity to provide continued service to you, a valued client. Thank you,

Sincerely,

Rachdi SabadoSRHI08-2705Commercial Account Executive

Tyco Integrated SecurityState license 8127M0364

fcgcDIffsflegra&d 8sevrity

December 2, 2015

Ttcm mcslctod sccolitvzatk Swat aliis033 amok, tltlcctl 60323Tle 636.643.3321fcm 633,643.336ttCtumttcmu commutumoetycoscm

Ms. Phyllis Adams, Chief Deputy Clerk

Cook County, IL Department of Purchasing

Clerk of the Circuit Court

69 West Washington Street-Suite 2500

Chicago, illinois 60602

Dear Ms. Adams,

The accounts lhted below ara.for security systems currently maintained and/or monitored by Tyco lntegrdtedSecurity for the Clerk of the CIrcuit Court of Cook County, IL

Cust 6

130-29138

130-29145

130-36578

130-38153

332-20604

130-29141

130-29142

13043179

131-24737

131-24738

131-09595

332-48740

130-55223

Name

Cook City Clerk Circuit

Caok City Clerk Gmuft

Clerk of the Grcuit

Circuit Court Qerk

Cook County Crlmlna I

6th District Court Building

Cook City Circuit Court

Clerk of the Grcult

2nd District Court Building

2nd District Court Building

Clerk of Circuit Ct

Clerk ef the Cltcua

Cook County Circuit Ct

Address

26SB5 California

26505 California

2650 5 California

26005 California

2650 5 California

16051SKedzleAve .

165015 Kedzie Ave

555 W Harrison St

56000ld Orchard Rd

Lacauon

Admln Bldg Evidence Room

Admln Bldg Evidence Room

Bond Room

Band Room

Courts Center

Bond Room Groupl

Etddencestorage Rm

Domestic Violence

Bond Room 2nd floor

50W Washington

. 50 W Washington

1022D 576th Ave

Room 1005

RloaleyCtrRmtl 01%

56NOld Orchard Rd Etsdence Room Lstgoar

City

Chicago

Chicago

Chicago

Chicago

Chicago

Markham

M arkham

Chicago

Skolde

Skolde

Chicago

Chicago

Brldgevietu

State Zlp

. IL 60608

IL 60608

IL 60608

IL 60608

IL 60608

IL 60426

IL N426

IL 60N7

IL '60077

IL 60077

IL 60602

IL 60602

IL 60455

Total

Per Annuln

$330.32

$337.34

$1,009t30 .

$2,677.27.

$360 62

$591.81

$591.81

$556.51

$361AO

$816.49

$3,397.30

$804.86

$1,249.00

$13,634.53

Very truly yours,

Michael J. Ultimo

Senior Commercial Account Executive

'tifg&47ifstegrl ted'SacuriQ

December 2, 2015

tice m team ted senet tvSeta eeet orlve

049 anmt, escort 60699Tee 690.645.9974Sar; 690.649.9900worse Wrolecomemiemoetteo.com

Ms. Phyllis Adams, Chief Deputy Clerk

Cook County, IL Department of Purchasing

Clerk of the Circuit Court

69 West Washington Street —Suite 2500Chicago, illinois 60602

Dear Ms, Adams,

The accounts listed below are for security systems currently maintained and/or monitomd by Tyco IntegratedSecurity for the Clerk of the Circuit Court of Cook County,'IL

Cust¹

130-45356

130.29144

130-29143

130-36579

332.50272

130-51108

Name

Clerk af the Greeit

Cook County Warehouse

Cook County Warehouse

Clerk of the Greeit

Clerk of the Greeit

Clerk of the Grcuit

Address

2323 5 Rockwell St

IOcation

Court

2323 5 Rackwell Ream 301

2323 5 Rockwell St Atchlve Room 3rd goor

23235 Rockwell St '.Riddance Vault 4thgaor

2323 5 Rockwell St Court 5th floor

2323 5 Rockwell St Rm 513Evidence Storage

Gty State

Chicago IL

Chicago IL

Chicago IL

Chicago IL

Chicago IL

Chicago IL

Zip

60608

60608

60608

Total

Per Annum

S720,00'337,34

3337.34

31,185.16

31,354.02

31,170,00

35,103.86

Very truly yours,

Michael J. Ultimo

Senior Commercial Account Executive

Contract No. 1245-395Vendor Name: Tyco Integrated Security

ATTACHMENT NO. 2

IDENTIFICATION OF SUBCONTRACTOR/SUPPLIER/SUBCONSULTANT,

M/WBE UTILIZATION PLAN, AND

ECONOMIC DISCLOSURE STATEMENT FORMS

Cook CountyOffice of the Chief Procurement Officer

Identification of Subcontractor/Supplier/Subconsuitant Form

OCPO ONLY:A DieouaiificetiooA Check Comoiete

The Bidder/Proposer/Respondent ("the Contracto(') will fully complete and execute and submit an Identification ofSubcontractor/Supplier/Subconsultant Form ("ISF")with each Bid, Request for Proposal, and Request forQualification. The Contractor must complete the ISF for each Subcontractor, Supplier or Subconsultant whichshall be used on the Contract. In the event that there are any changes in the utilization of Subcontractors,Suppliers or Subconsultants, the Contractor must file an updated ISF.

Bid/RFP/RFQ No.: 12-45-395

Total Bid or Proposal Amount: $92,60tL96

Contractor: Tyco Integrated Security

Authorized Contact Patricia Moelierfor Contractor:

Email Address(Contractor): pmoeller(ltyco.corn

Date: NIA

Contract Title: NIA

Subcontractor/Supplier/Subconsultant to be N/Aadded or substitute:Authorized Contact forSubcontractor/Supplier/ N/ASubconsultant:Email Address(Subcontractor): N/A

Company Address 2010 Swift Drive(Contractor):

Company Address(Subcontractor): NIA

City, State andZip (Contractor): Oak Brook, IL 60523Telephone and Fax(Contractor) 630-218-7507Estimated Start andCompletion Dates 1/1/1 6 through 12/31/1 6(Contractor)

City, State and Zip(Subcontractor):Telephone and Fax(Subcontractor)Estimated Start andCompletion Dates(Subcontractor)

N/A

NIA

NIA

Note: Upon request, a copy of all written subcontractor agreements must be provided to the OCPO.

Descrlotlon of Services or Suoolles Total Price of Subcontract forServices or Suoolles

NIA

The subcontract documents will incorporate all requirements of the Contract awarded to the Contractor as applicable.The subcontract will in no way hinder the Subcontractor/Supplier/Subconsultant from maintaining its progress on anyother contract on which it is either a Subcontractor/Supplier/Subconsultant or principal contractor. This disclosure ismade with the understanding that ths Contractor is not under any circumstances relieved of its abilities andobligations, and ls responsible for the organization, psr/ormsnce, snd quality of work. This form does not approveany proposed changes, revisions or modifications to the contract approved MBE/WBE Utilization Plan. Anychanges to the contract's approved NIBE/WBE/Utilization Plan must be submitted to the Office of theContract Compliance.

Contmctcr~ @QIW I)).M, AYa' .

Title M>7(Prime Contractor Signature Date

loc 0

OFFICE OF CONTRACT COMPUANCE

JACQUELINE GOMEZ

DIRECTOR

11BN. Clark, County Building, Room 1020 ~ Chicago, Illinois 6D602 ~ (312) 603-5502

TONE P RE C KWINKLE

PRESIDENT

Cook County Board

of Commrsslonsrs

RICHARD R.BOYKIN

1st Distuct

ROBERT STEELE

2nd District

February 25, 2016

Ms. Shannon E. Andrews

Chief Procurement Officer

118N. Clark Street

County Building-Room 1018

Chicago, IL 60602

Re: Contract No. 12-45-395 (Amendment No.4)

Alarm System Monitoring and Annual Maintenance

Department of Revenue

Dear Ms. Andrews:

Scsrss

~~casm cs sgl

cs srnDscornC CSCD

rst

QWCDrsl

Qrr\

cscss rss

JERRY BUTLER

3rd District

STANLEY MOORE

4th District

The Office of Contract Compliance is in receipt of the abovefetbrence contract amendment and has reviewed it forcompliance with the Minority- and Women- owned Business Enterprises (MBE/WBE) Ordinance. After careful review, it

has been determined this amendment Is responsive to the Ordinance.

DEBORAH SIMS

5th Drstrict

JOAN PATRICIA MURPHY

6th District

JESUS G. GARCIA

7th District

LUIS ARROYO, JR

6th Distuct

PETER N. SILYESTRI

9th District

BNDGET GAINER

10th Distdict

JOHN P. DALEY

11th District

JOHN A. FRITCHEY

12th District

LARRY SUFFREDIN

13th District

GREGG GOSLIN

14th District

IIMOTHY O. SCHNEIDER

15th District

JEFFREY R. TOBOLSKI

16th Distnct

SEAN M. MORRISON

17th District

Bidder: Tyco Integrated Services

Original Contract Value: $72,463.78Increased Contract Value: $91,890.75(Amendment No. 1)New Contract Value: $164,354.53Contract Extension: 12 months

New Contract Term: January 1, 2014 through December 31, 2014Increased Contract Value: $534.00 (Amendment No. 2)New Contract Value: $164,888.53

Increased Contract Value: $93,683.51 (Amendment No. 3)New Contract Value: $258,572.04

Contract Extension: 12 months

New Contract Term. January 1, 2015 through December 31, 2015Increased Contract Value: $92,604.96 (Amendment No. 4)New Contract Value: $351,177.00Contract Extension: 12 months

New Contract Term: January 1, 2016 through December 31, 2016Contract Goal: 35% MBE/WBE

Full M/WBE Waiver Granted: Due to the specilication and necessary requirements for performing the contract make it

impossible or economically infeasible to divide Ihe contract to enable the vendor to uglize MBEs and/or WBEs in

accordance with the applicable participation.

The 0%ce of Contract Compliance has been advised by the Requesting Deparlment that no other bidders are being

recommended for award. Original MBE/WBE forms were used in the determination of the responsiveness of this contract

Sincerely,

uel'omezContract Compliance Director

JG/ate

Cc: Adriaan Jelk-Brown, OCPO

Kevin Hickey, Juvenile Probation

$ Fiscal Responsibility f Innovative Leadership I Transparency tk Accountability g> Improved Services

MBE/WBE UTILIZATION PLAN - FORM 1

BIDDER/PROPOSER HEREBY STATES that all MBE/WBE iirms included in this Plan are certified MBEs/WBEs by at least one of the entities listed in the GeneralConditions —Section 19.

I, BIDDER/PROPOSER MBE/WBE STATUS: (check the appropriate line)

Bidder/Proposer is a certified MBE or WEE firm. (If so, attach copy of current Letter of Certi/ication)

Bidder/Proposer is e Joint Venture and one or more Joint Venture partners are certified MBEs or WBEs. (If so, attach copies of Letter(s) ofCertification, a copy of Joint Venture Agreement clearly describing the role of the MBE/WBE firm(s) and its ownership interest in the JointVenture and a completed Joint Venture Affidavit - available online at vAvw.cookcounivil cov/conirecicomoliance)

Bidder/Proposer is not a rxrrtified MBE or WBE firm, nor a Joint Venture with MBE/WBE partners, but will utilize MBE and WBE firms eitherdirectly or indirectly in the performance of the Contract. (If so, complete Secfions II below and the Letter(s) of Intent —Form 2).

Direct Participason of MBE/WBE Firms Indirect Parbcipstion of MBBWBE Firms

NOTE: Where goals have not been achieved through direct participation, Bidder/Proposer shall include documentation outlining efforts toachieve Direct Participation at the time of Bid/Proposal submbrsion, Indirect Participation will only be considered after all efforts toachieve Direct Participation have been exhausted. Only after written documentation of Good Faith Efforts is received will IndirectParticipation be considered.

MBEs/WBEs that will perform as subcontractors/suppliers/consultants include the following:

MBE/WBE Firm:

Address:

E-mail:

Contact Person:

Dollar Amount Parlicipationi $

Percent Amount of Participation:

Phone:

*Letter of Intent atlach ed?*Current Letter of Certification attached'

YesYes

No

No

MBE/WBE Firm:

Address:

E-maik

Contact Person:

Dollar Amount Participation: $

Percent Amount of Participation:

Phone:

'Letter of Intent attached'/

*Current Letter of Certification attached?YesYes

No

Nc

At/sch additional sheets as needed.

'etter(s) of Intent and current Letters of Certification ~met be submitted at the time of bid.

M/WBE Utilization Plan - Form 1 Revised: 01/29/2014

MBE/WBE LETTER OF INTENT ~ FORM 2

M/WBE Firm:

Contact Person:

Address:

City/sate:

Phone:

Zip:

Fax:

Certifying Agency:

Certification Expiration Date:

Ethnicity:

Bid/Proposal/Contract ¹:

FEIN ¹:

Email:

Participation: [ ] Direct [ ] Indirect

Will the M/WBE firm be subcontracting any of the goods or services of this contract to another firm?

[ ] No [ ] Yes —Please attach explanation. Proposed Subcontractor(s):

The undersigned M/WBE is prepared to provide the following Commodities/Servitude for the above named Project/ Contract; I/l

more space is needed fo roily describe hfrytrBE Ffim's proposed scope of work and/or payment schedule, affsch additional sheets)

Indicate the Dollar Amount, Percentane. and the Terms of Pavment for the above-described Commodities/ Services:

THE UNDERSIGNED PARTIES AGREE that this Letter of Intent will become a binding Subcontract Agreement for the abovework, conditioned upon (1) the Bidder/Proposer's receipt of a signed contract from the County of Cook; (2) UndersignedSubcontractor remaining compliant with all relevant credenfials, codes, ordinances and statutes required by Contractor, CookCounty, and the State to participate as a MBE/WBE firm for the above work. The Undersigned Parges do also certify that theydid not affix their signatures to this document until all areas under Description of Service/ Supply and Fee/Cost were completed.

Signature (M/WBE) Signature (Prime Bidder/Proposer)

Print Name Print Name

Firm Name Firm Name

Date Date

Subscdibed and sworn before me

this day of

Notary Public

, 20

Subscdibed and sworn before me

this day of

Notary Public

.20

SEAL SEAL

PETITION FOR WAIVER OF 55BE/WBE PARI'ICIPATION —FORhll 3

A. BIDDER/PROPOSER HEREBY REQUESTS:

FULL ISBEWAIVER FULL WBE WAIVER

REDUCTION (PARTIAL ISBE and/or WBE PARTICIPATION)

% of Reducffon for MBE Participation

% of Reducbon for WBE Partlcipa5on

B.REASON FOR FULIJREDUCTION WAIVER REQUEST

Bidder/Proposer shall check each item applicable fo its reason for a waiver requssL AddNonagy, suppor5ngdocumentation shall be submiffad with this request.

(1) Lack of sufficient qualified MBEs and/or WBEs capable of providing the goods or services requiredby the contract. (Please explain)

(2) The spedffcaffons and necessary requirements for perlbrming the contract make It impossible oreconomhelly infeasible to divide the contract to enable the conbactcr to uNhe MBEs and/or WBEs inaccrxdraxw with the applhable parhcipaffon. (Please explain)

(3) Price(s) quoted by potsngal MBEs and/or WBEs are above competitive levels-and increase cost ofdoing business and would make accepbmce of such MBE and/or WBE bid econombagy Impracgcable,taking into consideration the percentage of tobd contract price represented by such MBE and/or WBEbid. (Please explain)

(4) There are other relevant factors making it impossible pr qconomicafy infeasible to u6lize M BE and/orWBEffmw. (Pleaseexplatn) Qgi/p~~+(/} g

C. GOOD FAITH EFFORTS TO OBTAIN M BE/WBE PARTICIPATION

(1) Made fimeiy written solicffation to identiffed MIBEs and WBEs for utilization cfgoods and/or services;and pmvided MBEs and WBEs with a timely cpportunKy to review and obtain relevant specilicaffons,terms and condiTions of the proposal tc enable MBEs and WBEs to prepare an informed response tosogcffagon. (Attach of copy written sollcltatlons made)

(2) Used ths services and assistance of the Oiffce of Contract Compliance stalf. (Please explain)

(3) Timely notified and used the services and assistance of community, minority and women businessorganiza5ons. (Attach of copy written solicltations made)

(4) Folcwedup on Inlffal sogcffaffon of MBEs and WBEs to debmnlne if 5rms are interested in doingbusiness. (Attach supporting documentation)

(5) Engaged MBEs & WBEs for direcVindirect parbcipafion. (Please explain)

D. OTHER RELEVANT IblFORINATION

Affach any other documentation relative to Good Faith Efforis in complying viith MBE/WBE participabon

COOK COUNTYECONOMIC DISCLOSURE STATEMENT

AND EXECUTION DOCUMENTINDEX

Section Description Pages

Instructions for Completion of EDS EDS i —ii

Certifications

Economic and Other Disclosures, Affidavit of Child

Support Obligations, Disclosure of Ownership Interestand Familial Relationship Disclosure Form

Cook County Affidavit for Wage TheR Ordinance

EDS 1-2

EDS 3 —12

EDS 13-14

Contract and EDS Execution Page

Cook County Signature Page

EDS 15-17

EDS 18

SECTION 1INSTRUCTIONS FOR COMPLETION OF

ECONOMIC DISCLOSURE STATEMENT AND EXECUTION DOCUMENT

This Economic Disdosure Statement and Execution Document ("EDS") is to be completed and executedby every Bidder on a County contract, every Proposer responding to a Request for Proposals, and everyRespondent responding to a Request for Qualifications, and others as required by the Chief ProcurementOfficer, The execution of the EDS shall serve as the execution of a contract awarded by the County. TheChief Procurement Officer reserves the right to request that the Bidder or Proposer, or Respondentprovide an updated EDS on an annual basis.

Definitions. Terms used in this EDS and not otherwise defined herein shall have the meanings given tosuch terms in the Instructions to Bidders, General Conditions, Request for Proposals, Request forQualifications, as applicable.

Affiliate means a person that directly or indirectly through one or more intermediaries, Controls isControlled by, or is under common Control with the Person specified.

App/icant means a person who executes this EDS.

Bidder means any person who submits a Bid.

Code means the Code of Ordinances, Cook County, illinois available on municode.corn.

Contract shall include any written document to make Procurements by or on behalf ofCook County.

Contractor or Contracting Party means a person that enters into a Contract with theCounty,

Control means the unfettered authority to directly or indirectly manage governance,administration, work, and all other aspects of a business.

EDS means this complete Economic Disclosure Statement and Execution Document,including all sections listed in the Index and any attachments.

Joint Venture means an association of two or more Persons proposing to perform a for-profit business enterprise. Joint Ventures must have an agreement in writing specifyingthe terms and conditions of the relationship between the partners and their relationshipand respective responsibility for the Contract

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 Persons means any individual, corporation, partnership, Joint Venture, trust,association, Limited Liability Company, sole proprietorship or other legal entity.

Prohibited Acts means any of the actions or occurrences which form the basis fordisqualification under the Code, or under the Certifications hereinafter set forth.

Proposal means a response to an RFP.

Proposer 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.

RFQ means a Request for Qualifications issued to obtain the qualifications of interested parties.

EDS-I 8/2015

INSTRUCTIONS FOR COMPLETION OFECONOMIC DISCLOSURE STATEMENT AND EXECUTION DOCUMENT

Section 1: Instructions. Section 1 sets forth the instructions for completing and executing this EDS.

Section 2: Certifications. Section 2 sets forth certifications that are required for contracting parties underthe Code and other applicable laws. Execution of this EDS constitutes a warranty that all the statementsand certifications contained, and all the facts stated, in the Certifications are true, correct and complete asof the date of execution.

Section 3: Economic and Other Disclosures Statement. Section 3 is the County's required Economicand Other Disclosures Statement form. Execution of this EDS constitutes a warranty that all 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. The Applicant is required to keep all information provided in this EDS current andaccurate. In the event of any change in the information provided, including 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 time the County takes action, by filing an amended EDS orsuch other documentation as is required.

Additional Information. The County's Governmental Ethics and Campaign Financing Ordinancesimpose certain duties and obligations on persons or entities seeking County contracts, work, business, ortransactions, and the Applicant is expected to comply fully with these ordinances. For further informationplease contact the Director of Ethics at (312) 603-4304 (69 W. Washington St. Suite 3040, Chicago, IL60602) or visit the web-site at cookcountyil.gov/ethics-board-of.

Authorized Signers of Contract and EDS Execution Page. If the Applicant is a corporation, thePresident and Secretary must execute the EDS. In the event that this EDS is executed by someone otherthan the President, attach hereto a certified copy of that section of the Corporate By-Laws or otherauthorization by the Corporation, satisfactory to the County that permits the person to execute EDS forsaid corporation. If the corporation is not registered in the State of illinois, a copy of the Certificate 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 Officeof the Chief Procurement Officer must be submitted with this Signature Page.

If the Applicant is a member-managed LLC all members must execute the EDS, unless otherwiseprovided in the operating agreement, resolution or other corporate documents. If the Applicant is amanager-managed LLC, the manager(s) must execute the EDS. The Applicant must attach either acertified copy of the operating agreement, resolution or other authorization, satisfactory to the County,demonstrating such person has the authority to execute the EDS on behalf of the LLC. If the LLC is notregistered in the State of illinois, a copy of a current Certificate 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 Proprietorship" 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 the EDS.

EDS-ii 8/2015

SECTION 2

CERTIFICATIONB

THE FOLLOWING CERTIFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE. THE APPLICANT IS CAUTIONEDTO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE SIGNING THE SIGNATUREPAGE SHALL CONSTITUTE A WARRANTY BY THE APPLICANT THAT ALL THE STATEllilENTS, CERTIFICATIONS ANDINFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE AND CORRECT AS OF THE DATE Tl-IESIGNATURE PAGE IS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTY LEARNS THAT ANY OF THEFOLLOWING CERTIFICATIONS WERE FALSELY MADE, THAT ANY CONTRACT ENTERED INTO WITH THE APPLICANT SHAI LBE SUBJECT TO TERMINATION.

PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATION

No person or business entity shall be awarded a contract or sub-contract, for a period of five (5) years from the date ofconvicfion or entry of a plea or admission of guilt, civil or criminal, If that person or business entity:

1) Has been convicted of an act committed, within ths State of illinois, of bribery or attempting to bribe en officer oremployee of a unit of state, federal or local government or school district In the State of Illinois in that officers oremployee's official capacity;

2) Has been convicted by federal, state or local government of an act of bid-rigging or attempting to Vig bids as definedin the Sherman Anti-Trust Act and Clayton Act. Act. 15 U.S.C. Section 1 et ssqu

3) Has been convicted of bid-rigging or attempting to rig bids under the laws of federal, state or local government;

4) Has been convicted of an act committed, within the State, of pVice-fixing or attempting to fix prices as defined by theSherman Anti-Trust Act and the Clayton Act. 15 U.S.C. Section 1, et seqq

5) Has been convicted of price-fixing or attempting to fix prices under the laws the Sbrte;

6) Has been convicted of defiauding or attempting to defraud any unit of state or local government or school districtwithin the State of illinois;

7) Has made an admission of guilt of such conduct ss set forth in subsections (1) through (6) above which admission isa matter of record, whether or not such pemon or business entity was subject to prosecution for the offense oroffenses admitted to; or

8) Has entered a plea of nolo contendere to charge of bribeqr, price-fixing, bid-rigging, or fraud, as set forth in sub-paragraphs (1) through (6) above.

In the case of bribery or attempting to bribe, a business entity may not be awarded a contract if an offlclsl, agent or employeeof such business entity committed the Prohibited Act on behalf of the business entliy and pursuant to the direction orauthomation of an oflicer, director or other responsible official of the business entity, and such Prohibited Act occurred withinthree years prior to the award of the contract. In addiTion, a business entity shall be disqualified if an owner, partner orshareholder controlling, directly or indirectly, 20% or more of the business entity, or an officer of the business entity hasperformed any Prohibited Act within five years prior to the award of the Contract.

THE APPLICANT HEREBY CERTIFIES THAT: The Applicant has read the provisions of Section A, Persons and EntitiesSubject to Disqualificatio, that the Applicant has not committed any Prohibited Act set forth in Section A, and that award ofthe Contract to the Applicant would not violate the provisions of such Secfion or of the Code.

BID4tIGGING OR BID ROTATING

THE APPLICANT HEREBY CERTIFIES THAT: in accordance with 720 ILCS Sr33 E-11, neither the Applicant nor enyAffiliated Entity is bened from award oi this Contract as a result of a conviction for the violation of Stets isws prohibiting bid-rigging or bid rotating.

C. DRUG FREE WORKPLACE ACT

THE APPLICANT HEREBY CERTIFIES THAT: The Applicant will provide a drug free workplace, as required by (30 ILCS 580/3).

EDS-1 8/201 5

D. DELINQUENCY IN PAYMENT OF TAXES

THE APPLICANT HERES Y CERTIFIES THAT: The Applicant is not an owner or s party responsible for the payment of any taxor fee administered by Cook County, by a local municipalily, or by the illinois Department of Revenue, which such tsx or fee isdelinquent such ss baraward of s contract orsubcontrac! pursuant to the Code, Chapter 34 Section 34 171.

E. HUMAN RIGHTS ORDINANCE

No person who is a parly to a contract with Cook County ("County" ) shall engage in unlawful discdimination or sexual harassinentagainst any individual in the terms or conditions of employment, credit, public accommodafions, housing, or provision of Countyfacilities, services or programs (Code Chapter 42, Section 42-30 et seq.).

F. ILUNOIS HUMAN RIGHTS ACT

THEAPPLICANT HERESY CERTIFIES THAT: Itis in compliance with the illinois Human Rights Act (775 ILCS 5r2105), andagrees to abide by the requirements of the Act as part ofils contractual obligations.

INSPECTOR GENERAL (COOK COUNTY CODE, CHAPTER 34, SECTION 34-174 and Section 34-260)

The Applicant has not willfully failed to cooperate in an investigation by the Cook County Independent Inspector General or toreport to the Independent Inspector General any and afi information concerning conduct which they know to involve corruption, orother criminal activity, by another county employee or officiat, which concerns his or her oflice of employment or County relatedtransaction.

The Applicant has reported directly and without any undue delay any suspected or known fraudulent activity in the County'sProcurement process to the Oflice of the Cook County Inspector General.

CAMPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECTION 2-585)

THE APPLICANT CERTIFIES THAT: It has read and shall comply with the Cook County's Ordinance concerning campaigncontributions, which is codified at Chapter 2, Division 2, Subdivision II, Section 585, and can be read in its entirety atwww.municode.corn.

GIFT BAN, (COOK COUNTY CODE, CHAPTER 2, SECTION 2-574)

THE APPLICANT CERTIFIES THAT: It has read and shall comply with the Cook County's Ordinance concerning receiving andsoliciTing gifis and favors, which is codBed at Chapter 2, Division 2, Subdivision II, Section 574, and can be mad in its entirety atwww.municods.corn.

LIVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION34-160,'nless

expressly waived by the Cook County Board of Commissioners, the Code requires that a living wage must be paid toindividuals employed by a Contractor which has a County Contract and by afi subcontractors of such Contractor under a CountyContract, throughout the duration of such County Contract. The amount of such living wage is annually by the Chief FinancialOfficer of the County, and shall be posted on the Chief Procurement Officer's website.

The term "Contract" as used in Section 4, I, of this EDS, specifically excludes contracts with the following:

1) Not-For Profit Organizations (defined as a corporation having tax exempt status under Section 501(C)(3)of the UnitedState Internal Revenue Code and recognized under the filinois State not-for -profit law);

2) Community Development Block Grants;

3) Cook County Works Department;

4) Sheriffs Work Alternative Program; and

5) Department of Correction inmates,

EDS-2 8/201 5

SECTION 3

REQUIRED DISCLOSURES

1. DISCLOSURE OF LOBBYIST CONTACTS

List all personsthat have made lobbying contacts on your behalf with respect to this contract:

Nairie Address

2. LOCAL BUSINESS PREFERENCE STATEMENT (CODE, CHAPTER 34, SECTION 34-230)

Local business means a Person, including a foreign corporation authorized to transact business in fllinois, having a bona fideestablishment located within the County at which it is transacting business on the date when a Bid is submitted to the County, andwhich employs the majority of its regular, full-time work force within the County. A Joint Venture shall constitute a Local Business if oneor more Persons that qualify as a "Local Business" hold interests totaling over 50 percent in the Joint Venture, even if the Joint Venturedoes not, at the time of the Bid submittal, have such a bona fide establishment wilhin the County.

a) Is Applicant a "Local Business" as defined above?

Yes: No:

b) If yes, list business addresses within Cook County:

c) Does Applicant employ the majority of Its regular full-time workforce within Cook County?

Yes: No:

3. THE CHILD SUPPORT ENFORCEMENT ORDINANCE (CODE, CHAPTER 34, SECTION 34-172)

Every Applicant for a County Privilege shall be in full compliance with any child support order before such Applicant is entlged to receive orrenew a County Privilege. When delinquent child support exists, the County shall not issue or renew any County Pmiilege, and mayrevoke any County Privilege.

All Applicants are required to review the Cook County Affidavi of Chfld Support Obligations attached to this EDS (EDS-5) andcomplete the Affldavlt, based on the Instructions In the Affidavi.

EDS-3 8/2015

4. REAL ESTATE OWNERSHIP DISCLOSURES.

The Applicant must indicate by checking the appropriate provision below and providing all required information that eiEmen

a) The following is s complete list of all real estate owned by the Applicant in Cook County:

PERMANENT INDEX NUMBER(S); /(r'2 333 f)O /(3()8 d)

1(4 ~o<rJo~M

(ATTACH SHEET IF NECESSARY TO LIST ADDITIONAL INDEXNUMBERS)

OR:

b) The Applicant owns no real estate in Cook County.

5. EXCEPTIONS TO CERTIFICATIONS OR DISCLOSURES.

If the Applicant is unabls to cerlify to any of the Certifications or any other statements contained in this EDS and not explained elsewhere In

this EDS, the Appllcan~tst explain below:

Poof

If the letters, 'NA", the word "None" or "No Response" appears above, or if the space is left blank, it will be conclusively presumed that theApplicant car(iliad to ail Corti(Ice(tons and other statements contained in this EDS,

EDSA 8/201 5

COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT

The Cook County Code of Ordinances (I]2-510 et seq.) requires that any Applicant for any County Action must disclose informationconcerning ownership interests in the Applicant. This Disclosure of Ownership Interest Statement must be completed with allinformation current as of the date this Statement is signed. Furthermore, this Statement must be kept current, by filing an amendedStatement, until such time as the County Board or County Agency shall take action on the application. The information contained inthis Statement will be maintained in a database and made available for public viewing.

lf you are asked to list names, but there are no applicable names to list, you must state NONE. An incomplete Statement will bereturned and any action regarding this contract will be delayed. A failure to fully comply with the ordinance may result in the actiontaken by the County Board or County Agency being voided.

"Appl/ can!" means any Entity or person making an application to the County for any County Action.

"County Action" means any adion by a County Agency, a County Department, or the County Board regarding an ordinance orordinance amendment, a County Board approval, or other County agency approval, with respect to contracts, leases, or sale orpurchase of real estate.

"Person" "Enlily" or "Legs/ Entify" means a sole proprietorship, corporation, partnership, association, business trust, estate, two ormore persons having a joint or common interest, trustee of a land trust, other commercial or legal entity or any beneficiary orbeneficiaries thereof.

This Disclosure of Ownership Inteiest Statement must be submitted by:

1.An Applicant for County Action and

2. A person that holds stock or a beneficial Interest in the Applicant and is listed on the Applicant's Statement (a "Holder" ) must file aStatement and complete ¹1 only under Ownership Interest Declaration.

Please print or type responses dearly and legibly. Add additional pages if needed, being careful to identify each portion of the form towhich each addiTional page refers.

This Statement ls being made by the [ Lapp(leant or (

[ ] Original Statement or [This Statement is an

] Stock/Beneficial Interest Holder

] Amended Statement

2 ~~)>yFEIN NO.:

State:

FaxNumber: /i~6 [ S 37hZ/

Identifying Information:

Name ~4] W~TI?YM~1D/B/A: iL J 6Street Address:N/8 +&Ij~lCity: 8BW~dgdPhone No.: kA 8YS 890

Zip Code: dl C~ZE..;i: aA ()E(/'e ~V@.W4

Cook County Business Registration Number:(Sole Proprietor, Joint Venture Partnership)

Corporate File Number (if applicable):

Form of Legal Entity:

[ ] Sole Proprietor [ ] Partnership Corporation [ ] Trustee of Land Trust

[ ] Business Trust [ ] Estate [ ] Association [ ] Joint Venture

[ ] Other (describe)

EDS-5 8/2015

Ownership Interest Declaration:

List the name(s), address, and percent ownership of each Person having a legal or beneficial interest (including ownership) ofmore than five percent (5%) in the Applicant/Holder.

)/fKAddress Percentage Interest In

Applicant/Holder

2 If the interest of any Person listed in (1) above is held as an agent or agents, or a nominee or nominees, list the name andaddress of the principal on whose behalf the interest is held.

Name of Agent/Nominee ~ Name of Principal Principal s Address67~

Is the Applicant constructively controlled by another person or Legal Entity7 [ ] Yes [ ] No

If yes, state the name, address and percentage of beneficlal interest of such person, and the relationship under which suchcontrol is being or may be exercised.

Name

L/WPercentage ofBeneficial Interest

Relationship

Corporate Officers, Members and Partners information:

For all corporations, list the names, addresses, and terms for afi corporate ofllcers. For all limited liability companies, list the names,addresses for all members. For all partnerships and joint ventures, list the names, addresses, for each partner or joint venture.

Name Address Title (specify title ofOffice, or whether manageror partner/joint venture)

Term of Office

Declaration (check the applicable box):

[~] I state under oath that the Applicant has withheld no disclosure as to ownership interest in the Applicant nor reservedany information, data or plan as to the intended use or purpose for which the Applicant seeks County Board or other County

Agency action.

[ ] I state under oath that the Holder has withheld no disclosure as to ownership interest nor reserved any informafion required tobe disdosed.

EDS-7 8/2015

COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT SIGNATURE PAGE

Gnu~Name of Authorize Applicant/Hold~ RIlpresentagve (please print or type) Title

Signature Date

Ja jSryyL&AUTV H-~~ f,8a dA-3'E-mail address Phone Number

Subscribthis lW

My commission expires: g ~M I/ Y

Notary Public Signature Nd ary Seal OFFICIAL SEAL

PATRICIA R MOELLER

Notary Public - State of lllinfae

My Commission Expires Eep 28, 2018

EDS-8 8/2015

COOK COUNTY BOARD OF ETHICS69 W. WASHINGTON STREET, SUITE 3040

CHICAGO, ILLINOIS 60602312/603-4304 Once 312/603-9988 Fax

FAMILIAL RELATIONSHIP DISCLOSURE PROVISION

Nenotism Disclosure Reauirement:

Doing a significant amount of business with the County requires that you disclose to the Board of Ethics the existence of any familialrelationships with any County employee or any person holding elective office in the State of Illinois, the County, or in anymunicipality within the County. The Ethics Ordinance defines a significant amount of business for the purpose of this disclosurerequirement as more than $23,000 in aggregate County leases, contracts, purchases or sales in any calendar year.

If you are unswe of whether the business you do with the County or a County agency will cross this threshold, err on the side ofcaution by completing the attached familial disclosure form because, among other potential penalties, any person found guilty offailing to make a required disclosure or knowingly filing a false, misleading, or incomplete disclosure will be prohibited from doingany business with the County for a period of three years. The required disclosure should be filed with the Board of Ethics by January1 of each calendar year in which you are doing business with the County and again with each bid/proposaVquotation to do businesswith Cook County. The Board ofEthics may assess a late filing fee of $100 per day atter an initial 30-day grace period.

The person that is doing business with the County must disclose his or her familial relationships, If the person on the County lease orcontract or purchasing from or selling to the County is a business entity, then the business entity must disclose the familialrelationships of the individuals who are and, during the year prior to doing business with the County, were:

~ its board of directors,~ its oiffcers,~ its employees or independent contractors responsible for the general administration of the entity,~ its agents authorized to execute documents on behalf of the entity, and~ iis employees who directly engage or engaged in doing work with the County on behalf of the entity.

Do not hesitate to contact the Board of Ethics at (312) 603-4304 for assistance in determining the scope of any required familialrelationship disclosure.

Additional Definitions:

"Familial relationship" means a person who is a spouse, domestic partner or civil union partner of a County employee or State,County or municipal official, or any person who is related to such an employee or official, whether by blood, marriage or adoption, asa:

C ParentC ChildC BrotherC Sister

Aunt

Uncle

NieceNephew

3 Grandparent

2 Grandchild3 Father-in-law3 Mother-in-law

I Son-in-lawI Daughter-in-lawI Brother-in-lawI Sister-in-law

j Stepfather3 Stepmother3 Stepson2 Stepdaughter

I StepbrotherI StepsisterI Half-brotherI Half-sister

EDS-0 8/2015

COOK COUNTY BOARD OF ETHICSFAMILIAL RELATIONSHIP DISCLOSURE FORM

PERSON DOING OR SEEKING TO DO BUSINESS WITH THE COUNTY

Name of Person Doing Business with the County:

Address of Person Doing Business with the County:

Phone number of Person Doing Business with the County:

Email address of Person Doing Business with the County:

If Person Doing Business with the County is a Business Entity, provide the name, title and contact information for theindividual completina this disclosure on behalf of the Pj„rson Doing Business with the County:l~ /s-f ~(hkJ ~6-~~Ic.)crit ~T 14'd)/tlfI, /',& Al'fc ~86i<J

DESCRIPTION OF BUSINESS WITH THE COUNTYAppend additional pages as needed and for each County lease, contract, purchase or sale sought andJ'or obtainedduring the calendar yern of this disclosure (or the proceeding calendar year ifdisclosure is made on January /),identify:

The lease number, coniract number, purchase order number, request for proposal number and/or request for qualification

number associated with the business you are doing or seeking to do with the County:

The aggregate dollar value of the business you are doing or seeking to do with the County: S

The name, title and contact information for the County official(s) or employee(s) involved in negotiating the business you aredoing or seeking to do with the County:

The name, title and contact information for the County official(s) or employee(s) involved in managing the business you aredoing or seeking to do with the County:

C. DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYEES OR STATE. COUNTY ORMUNICIPAL ELECTED OFFICIALS

Check the box that applies and provide related information where needed

CI The Person Doing Business with the County is an individual and there is no familial relationship between this individual

and any Cook County employee or any person holding elective office in the State of Illinois, Cook County, or any

municipality within Cook County.

The Person Doing Business with the County is a busiaess entity and there is no familial relationship between any member

of this business entity's board of directors, officers, persons responsible for general administration of the business entity,

agents authorized to execute documents on behalf of the business entity or employees directly engaged in contractual workwith the County on behalf of the business entity, and any Cook County employee or any person holding elective office in theState of Illinois, Cook County, or any municipality within Cook County.

EDS-10 8/2015

COOK COUNTY BOARD OF ETHICSFAMILIAL RELATIONSHIP DISCLOSURE FORM

CI The Person Doing Business with the County is an individual and there is a familial relationship between this individual

and at least one Cook County employee and/or a person or persons holding elective office in the State of Illinois, CookCounty, and/or any municipality within Cook County. The familial relationships are as follows:

Name of individual DoingBusiness with the County

Name of Related County Title and Position ofRelated Nature of Familial

Employee or State, County or County Employee or State, County Relationship

Municipal Elected Official or Municipal Elected Official

Ifmore space is needed, attach an additional sheet following the above format.

The Person Doing Business with the County is a business entity and there is a familial relationship between at least onemember of this business entity's board ofdirectors, offfcers, persons responsible for general administration of the business

entity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged in

contractual work with the County on behalf of the business entity, on the one hand, and at least one Cook County employeeand/or a person holding elective office in the State of Illinois, Cook County, and/or any municipality within Cook County, onthe other. The familial relationships are as follows:

Name ofMember ofBoardof Director for BusinessEntity Doing Business with

the County

Name ofRelated County Title and Position ofRelated Nature ofFamilial

Employee or Stem, County or County Employee or Stale, County RelationshipMunicipal Elected Ofticial or Municipal Elected Olficial

Name of Office for Business Name ofRelated County Title and Position ofRelated Nature of Familial

Entity Doing Business with Employee or State, County or County Employee or State, County Reladouship*

the County Municipal Elected Official or Municipal Elected Oigcial

EDS-11 8/2015

ere xassremc M//mm%"'errier/ As@ 0( c w —- '"wm |

Name ofPerson Responsible

for thE GeecralAdminhtrstion of the

Business Entity DoingBusmem wldl fhe Countir

¹me ofRelsfed County Title end Position ofRelated

Employee or State, County or Comsy Bmploycc or State, County

Mant@pal Elected Official or Mmdcipal Blected Oigctal

Natme ofPamiiialRehsionship

Name ofAgrmt Authorized

to Exccufa Documents for

Business Batity DoingBuiiness with the Coursy

Name ofRelsted Connty Titie andPosition ofgelatedEmployee or Sbue, County or County Bmployee or Stare, County

Municipal Blecfmi Ogfcial cr Muaicipal Elected OtBchd

Nanna ofPamiSelRcbrdonship

Name ofEmployee ofBusiness Esdty Directly

Engaged in Doing Business

with the County

Name ofRclaad County

Employee or Stare, County orMunicipal Elected OfSciel

Title snd PStree, CountyOfScial

Nabue ofFamilial

Rehtionship'f

more space te needed ter ach an add!tionat sheet follow icg the above format.

VERIFICATION: To the best ofmy knowledge, the information I have provided on this disdosnm form is accunria and complete. Iacknowledge that sn inaccurrdeyr incomplete disclosure is punishable by law, mcluding but not limited to Sacs and debarment.

/ ddt'sr~. CfN re 07/Signatu'fe oPkeciphmt Date

SUBMIT COMPLETED FORM TO: Cook County Board ofEthics69 West Washington Street, Suite 30ri0, Chicago, IBhmis 60602OIBce (312)603A304 —Pax (312)603-9988CookCounty.EthicsecookcountyiLgov

Spouse, domestic partner, civil union partaer or parent, child, sibling, aunt, uncle, niece, nephew, grandparent or grandchild

by blood, marriage (ie, la lawae~ ~—~—='FRCIALSEAL

PATRICIA R'OELLER

Notary Public - State of Illinois

I~My Commission Expires Sep 28, 2018

I

EDS-12 5/2015

SECTION 4

COOK COUNTY AFFIDAVIT FOR WAGE THEFT ORDINANCE

Effective May 1, 2015, every person, inc/udlnc subsrenr/el Ownenr, seeking a Contract with Cook County must comply with the Cook County Wage ThsOrdinance sst forth in Chapter 34, Article IV, Section 179. Any Person/Substantial Owner, who fails to comply with Cook County Wage Theft Ordinsnmmay request that the Chief Procurement Officer grant a reduction or waiver in accordance with Section 34-179(d).

"Contract" means any written document to make Procurements by or on behalf of Cook County.

"person" means any individual, oorporation, partnership, Joint Venture, trust, association, limited liability company, sole proprietorship or other legal enmy.

"Pmcursrnnn" means obtaining supplies, equipment, goods, or services of sny kind.

"Substenl/a/ Owner" means any person or persons who own or hold a twenty-five percent (25%) or more percentage of interest in any business enfitseeking a County Privilege, induding those shareholders, general or limited partners, beneficiaries and principals; except where a business entity is aindividual or sole proprietorship, Substantial Owner means that individual or sole proprietor.

All Persons/Substantial Owners are required to complete this affidavit and comply with the Cook County Wage Theft Ordinance before any Contrad i

awarded. Signature of this form constitutes a certification the Information provided below ls correct and complete, and that ths individual(s) signing this forrhas/have personal knowlsdce of such information.

I. Contract Information:

Contract Number: Q V4County Using Agency (requesting Procurement):

II. Person/Substantial Owner Information:

Person (Corporate Entity Name): ~M ~R3 AZkTKG

Substantial Owner Complete Name:

GC C /J f' 4m

FEINS 8 0 ~D /00&7Date of Birth: ejwStreetAddress: P/6 SIPjF jCity: /PWWWKHome Phone: ulcc

E-mail address: A/ JW

State:

Driver's License No: P /WZip: IgdW3

IIL Compliance with Wage Laws:

Within the past five years has the Person/Substantial Owner, in any judicial or administrative proceeding, been convicted of, entered aplea, made an admission of guilt or liability, or had an administrafive finding made for committing a repeated or willful violation of any ofthe following laws:

////no/s Wage Payment and Collection Acf, 820/LCS 115/1 et seq., YES o+NO

////no/s Minimum Wage Acl, 820 /LCS 105/f el seq., YES or Q////no/s WorkerAdjustmentand Re/rs/ning Notification Ac/, 820/LCS 85'1 etseq., YES o 0

Employee Classification Act, 820 /LCS 185/1 et seq., YES or 0

Fair Labor Standards Ac/of 1938, 29 U S C, 201, et sag., YES o NO

Any corn psrab/e state s/s/u/e or regulation of any state, which governs the payment of wages YESo NO

If the Person/Substantial Owner answered "Yes" to any of the questions above, it is ineligible to enter into a Contract with CookCounty, but can request a reduction or waiver under Section IV.

EDS-13 8/201 5

IV. Request for Waiver or Reduction

If Person/Substantial Owner answered "Yes" to any of the questions above, it may request a reducUon or waiver inaccordance with Section 34-179(d), provided that the request for reduction of waiver is made on the basis of one or more ofthe following actions that have taken place:

There has been a bona fide change in ownership or Control of the ineligible Person or Substantial OwnerYES or NO

Disciplinary action hss been taken against the individual(sj responsible for the acts giving rise to the violationYES or NO

Remedial action has been taken to prevent a recurrence of the acts giving rise to the dlsqusltgcalion or defaultYES or NO

Other factors that the Person or Substantial Owner believe are relevant.YES or NO

The Person/Substantial Owner must submit documentation to suooort tire basis of its reauest for a reduction or waiver. The ChiefProcurement Officer reserves the riant to make additional I novi ries and reau est additional documentation.

V. AffirmationThe Person/Substantial Owner affirms that all stateme ntained In the Affidavit are true, accurate and complete.

O.ten4-/4-y'4

Name of Person signing (Print): ZW~ Nj~~ Title: ~~ M~ /P}'f riLS-)6 Mbscribed and sworn to before me this le) day of ~t4 ~,20 jio

Votary Public SignatureNote: The above information is subject to veri@cat(on prior to the rf vsrd of ehe C(gtegRIILtSEAI

I PATRICIA R MOELLERNotary Pubgc - Stets of Rlinois

My Commission Expires Sep 28, 2018

EDS-14 8/2015

SECTION 5

CONTRACT AND EDS EXECUllON PAGEPLEASE EXECUTE THREE ORIGINAL PAGES OF EOS

The Applicant hereby ceriiges and warrants that all of the statements, certlflcagons and representalons set forth in this EDS are true,complete and correct; that the Applicant ls in full compliance and will continue to be in compgance throughout the term of the Contract orCounty Privilege issued to the Applicant with ag the policies and requirements set forth in this EDS; and that all facts and informagonprovided by the Applicant in this EDS are true, complete and conect. The Applicant agrees to inform the Chief Pmcurement Officer in

writing if any of such statements, ceriifications, representations, facts or information becomes or is found to be untrue, incomplete orincorrect during the term of the Contract or Couniy Privilege.

Execution by Corporation/

Tv/s ~wrxkeP S~urir,$ x aorrrrrjr'/croo& i/'Ri~- k~.Corporation's Name i President's Printed Name and Signature

Lf'@ 6 YS ~kl/ L0er ~~a 7'XM,derTelephone Email

Secretary Signature Date

Execution by LLC

LLC Name *Member/Manager Printed Name and Signature

Date Telephone and Email

Execution by Partnership/Joint Venture

Partnership/Joint Venture Name *Partner/Joint Venturer Printed Name and Signature

Date Telephone and Email

Execution by Sole Proprietorship

Printed Name Signature Assumed Name (if applicable)

Date Telephone and Email

SFlobus ~ gt

My commission expires:

q./~/(~srntarv-cleol

OFFICIAL SEAL*If the operating agreement, partnersht > agreemeprtldhfpftuSSISHLSjgpuments re pjiring execution by multiple members, managers,partners, or joint venturers, please corti piete dA8%%84480 aSHIHesklHSobtract a| p EDS Execution pages.

MY Commission Expires Ssp 28, 2pt 8

EDS-15 8/2015