chin inc. - cook county,...

Contract No. 1455-13763BVendor Name: R.M. Chin & Associates, Inc.

AMENDINENT NO. 1

This Amendment modifies Contract No. 1455-13763B,for Construction Management Professional Servicesby and between the County of Cook, illinois, herein referred to as "County" and R.M. Chin & Associates, Inc.,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 Officeron December 12, 2014, (hereinafter referred to as the "Contract" ), wherein the Contractor is to provide

construction management services (hereinafter referred to as the "Services" ) from December 15, 2014through December 14,2016, with three (3), one year renewal options, in an amount not to exceed $140 000 00and

Whereas, the Contract will expire December 14, 2016, and the agreed upon Services are still required; and

Whereas, a renewal is desired for the continuation of Services; and

Whereas, an increase in the amount of $375,000.00 is required for the continuation of Services, and

Whereas, the County and Contractor desire to renewthe Contract for 12 months beginning on December15,2016.

Now therefore, in consideration of mutual covenants contained herein, it is agreed by and between the partiesto amend the Contract as follows:

1. The Contract is renewed through December 14, 2017.

2. The Contract is increased by $375,000.00 and the Total Contract Amount is revised to $515,000.00.

3. The attached Economic Disclosures Statement, Identification of Sub-Contractors/Suppliers/Sub-

Consultants Form and DBE Utilization Plan forms are incorporated and made a part of this Contract.

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

In witness whereof, the County and Contractor have caused this Amendment No, 1 to be executed on the

date and year last wdtten below.

County of Cook, illinois

B„: W rkChief Procurement Officer

R.M.Chin &As ci, Inc.

Type or p

Date: 5 M@e'CI((oRev 1/1/15

V//0/if/

CONTRACT NO. 1455-137538A1

Cook CountyOffice of the Chief Procurement Otffcer

Identification of Subcontractor/Supplier/Subconsultant Form

OCPO ONLY:f) DianuniificatinnO Check Comnkttn

The Bidder/Proposer/Respondent ("the Contractor" ) will fully complete and execute and submit an Identification ofSubcontractor/Supplier/Subconsultant Form (dISFd) with each Bid, Request for Proposal, and Request forQualiTicahon. 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,:No. 145-13763B

Total Bid or Proposal Amount:

contractor: R.M. Chin &Associates, Inc.

Authorized Co~tact Eileen Chinfor Contractor:

Email Address eiieenc(Brmchin.corn(Contmctor):

Company Address 500 W. 18th Street(Contractor):

Zip (Contractor) +~8'elephoneand Fax 312 595 2ppp /312 544 p999

(Contractor)Estimated Start andCompletion Dates(Contractor)

Date: gi+//PCcntraot Title Canstructiun Management Professional Services

Subcontractor/Supplier/Subconsultant to be g Q M,crit Xnl c"added or subslitule:Authorized Contact for 't

Subcontractor/Supplier/ p tLmSubconsultant:Email

Address'Subcontractor):

Sitds N, Lddd~ du.t A>f-.Compsny Address(Subcontracto

City, State and Bp(Subcontractor):TelePhone snd Fax Qtt. ) TB ) - O lo I(Subcontractor) (gd13:%BR - 'f33 IS ti t d dt d ~

S/d/ i'dCompletion Dates(Subcontractor) t~)t '/

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

Descrlotlon of Services or Suoolles

Pro/essiunat Construction Management Services

Total Price ofSubcontract for

Services or Suoolies

It'3 'boo.cm (or~,)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/Subconsultsnt 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 the Contractor Is not under any drcumstances relieved of Its abilges sndobligations, and is responsible for the organization, performance, and qualiiy of work. This form does not appmveany proposed changes, revisions or modifications to the contract approved MBE/WBE Utilization Plan. Anychanges to the contract's approved MBE/WBE/Utilization Plan must be submitted to the Office of theContract Compliance.

ContractorK% Chin &Associates, Inc.Name .

Eileen Chin, Preside/It

Prime ContiapbSr Slgnatuie Date/ j

ISF-I

OFFICE OF CONTRACT COMPLIANCE

JACQUEUNE GOMEZ

DIRECTOR

11SN. Clark, County Building, Room 1020 ~ Chicago, illinois 60602 ~ (312) 603-5502

August 9, 2016

TONI PREC KWINKLE

PRESIDENT

Cook County Boonl

of Commissioners

RICHARD R. BOYIGN

1st Distdict

ROBERT STEELE

2nd District

Ms. Shannon E. Andrews

Chief Procurement Ofgcer

118N. Clark St.

County Building-Room 1018

Chicago, IL 60602

Re: Contract No. 1455-13763B(Amendment No. 3)Construction Management Professional Services

Bureau of Economic Development

JERRY BUTLER

3rd Distdict

STANLEY MOORE

4th District

DEBORAH SIMS

5th District

JOAN PATRICIA MURPHY

6th District

JESUS G. GARCIA

7th District

LUIS ARROYO, JR

Bth District

Dear Ms. Andrews:

The Otgce of Contract Compliance is in receipt of the above referenced contract amendment and hasreviewed it for compliance 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.

Bidden R.M.Chin 8 Associates

Original Contract Value: $140,000.00

Increased Contract Value: $375,000.00 (Amendment No. 1)

New Contract Value: $515,000.00

Contract Extension: 12 Months

New Contract Term: December 15, 2016 through December 14, 2017

Contract Goal: 35% DBE

PETER N. SILVESTRI

9th District

BRIDGET GAINER

10th District

M BE/WBE

d Escoto", Inc.

R.M. Chin & Associates

StatusDBE-9

DBE-7

Cergfvlna Aoencv

City of Chicago

City of Chicago

Commitment"

22% (Direct)

78% /Direct)

100% Total

JOHN P. DALEY

11th District

JOHN A. FRITCHEY

12th Distdict

LARRY SUFFREDIN

13th District

'Commitment percentages are based on the new total contract amount

The Oflice of Contract Compliance has been advised by Ete Requesting Deparbnent that no other bidders are

being recommended for award. Original MBE/WBE fonna were used in the determination of the

responsiveness of this contract.

GREGG GOSUN

14th Distdict

TIMOTHY O. SCHNEIDER

15th District

q Gomez

Contract Compliance Director

JEFFREY R. TOBOLSIG

16th DistdictJG/smp

SEAN M. MORRISON

17th District

cc: Edmund Rendon, OCPO

Jane Homatein, Dept, of Planning and Development

$ Fiscal Responsibility f Innovative Leadership IIITransparency & Accountability Q!EJJ Improved Services

DBE UTILIZATION PLAN - FORM 1

BIDDER/PROPOSER HEREBY STATES that all DBE fimm included in this Plan me certified DBEs by d least ane of the entities listed in the General Canditions-Section 19.

I. BIDDER/PROPOSER SIBE/WBE STATUS: (check ths appropriate line)

Bidder/Proposer is s certified DBE firm. (If so, attach copy af mirrent Letter of rliTicstion)

Bidder/Proposer h a Joint Venture and one or more Joint Venture partners are cerliyisd DBEs. (If so, attach copies of Letter(s) af Certilicatian,a copy of Joint Venture Agreement dearly describing the role of the DBE finn(s) snd its ownership interest in the Joint Venture and acompleted Joint Venture Affidavit -available online at www.cookcountvfi.aov/contractcomalisncs)

Bidder/Proposer h not a certified DBE fmn, nar a'oint Venture with DBE parlnws, but will ufilize DBE firms either directly or indirectly in theperformance af the Contract. (If so, complete Sections II below and the Letter(s) af Irdent —Form 2).

Direct Parthdpafion of DBE Firms Indirect Pargcipstion of DBE Firms

NOTE: Whee goals have not been achieved through direct paklcdpation, Bidder/Proposer shall include documentation outlining effoka toachieve Direct Paklclpatlon at the time of Bid/Proposal submission. Indirect Pargcfpagon wgl only be considered after all efforts toachieve Direct Paklclpation have been exhausted. Only after wrlgen documentation of Good Faith Efforts ls received wig IndirectParticipation be considered.

DBEs that will perform as subcontractors/suppliers/consultants indude the following:I

DBEFI/m: 4 E5c.~i~, Mc..Address: elm h(. LrBAS rs JtzU B 5~ rprk macr O.se i cn z. Sn G w o ~ I

Emai: 4kdscc Trn m $45o~f~sac . t.~~

Contact Persan FR% o ck ES C~ ~ Fh . (Skn,g

Dollar Amount Participation; $ (~~ i 3 (94»4 c nTrtJs~ d ~diesis Sr v I)Percent Amount of Participation:

*Letter of Inlsnt aasched? Yes X No

*Current Letter of Certification attached? Yes~ No

DBE Firm/

Address:

E-maik

Contact Person:

Dollar Amount Participation: $

Percent Amount af Participation:

Phone,

"Letter of Intent attached'/ Yes'Current Letter of Certification attached? Yes

No

No

Attach sddiyans/sheets as needed.

*Letter(s) of Intent and current Letters of Ceklgcsgon IEBM be submgted at the time of bid.

DBE Utilization Plan - Form 1 Revised: 01/29/2014

DBE LETTER OFi

DBE Firm: k ~ >~rwr 3'nc..

I

Contact Person; A Son o( K h corno

Address: 'A1nr fo ~annul A>%., A f xnno

Cgyfgtate'. CI4 I CAO o Xr 7jp 4o r, I I

Phonrr{ )ran ) 7'51 rrto1 Fax(r.Sr') 7(f1'>hx

Emalk 4 Jtcscrho rh r(EIfo(to Iroc, Con

INTENT - FORM 2

CertifyingAgency: Ctxw urn Crnhonc» .Dfr'r. rrdfrroodos

Cerllgcagon Explragon Date: /l /f gh

Ethnicity: shier nw'i c

Btdiplopos~ct: INdd' fa7CZ dy

FEINM 3(r Z 1 'f '[11

a&patton: [rr) Direct [ ] tnrgiect

Ihgt the DBE finn be subcontracting any of Ihe goods or services of this contract to another firm'f

PQ No [ )Yes- Please attach explsnagon. Proposed Subcontrsctur(s):

The undersigned DBE is prepared to provide Sre following Commorggssfgeniices for Ere shove named Pro)acti Contract ftfrnors

specs b needed lo fully describe DBEFinn's pnposod scope ofwork and'or pnymonl sohuhdn otloch addi llonnl shsnb]

Co~hyn r.-,t~ I)rLpv pres hr r grJJo w /w va rue. w"s-ghrr-trc ton%tron [email protected].<d .

Indtcrrie the Dollar Amount, Pnrcsntaas. and the Terms of Psvmsnt for the abowHhmcrihed Commodilhml Services:

gL I ( guns. 0 Jrlrtr cv- s.

THE UNDERSIGNED PARTIES AGREE Smt this l.sitar of Inhmt wil! become a biMng Subcontract Agreement for Ihe abwework, condigcned upon (I) ths BiddsrlPmposer's receipt of a signed contract from tha County of Cock; (2) Undendgned

Subconhactor remaining compliant with ag relevant cmdengab, codes, ordinances and statutes mashed by Contisckrr, Cook

County, snd the Sale to pmtlcipste as a DBE grm for the sbnm work. The Underiigned Psrges do abo cergfy that they dkl not

Sgnahrre (DBEj Sgnstureg'dnm Bhfder/Proposer)

Kdb~rtecr d'L. $Cu4 6 1 L'L4 C lardPrint Name Print Name

C2) lcrSMM,54C Cthrru ih ASSocrnvMS, 5 C.

Finn Name

l/co/IroDate

Subscribed and sworn behre me

[email protected] of JM,EOJlk,NolmyPubllc GJLJL lu(~

~/N/~&

Subscribed and sworn before me

Ibis A day of J&ycy,20~

OFRCIAL SEALJACALYN OESCOTC

Notary Puhac - State ol SandsMy Commission Expires Msy 10, 2018

DSE Utigxstlon Plan -x nun w — ———~OEEICIAL SEAL

MIT HORVATH iNomry Pule - Stem ol Imaols

My Comrmssmn Expires Osc 0, Eat 7I 4

an ierf $$i Nnvl

RRNNICSSICIIRLlNL cwnmmsezzre

zzrrhlez sr wrrws..lMfnehgl ~pnltarrf zurrr zerzat,plNHeseeseW

August 9, 2016

Sandra Moses-Potts

Contract Compliance Officer

Cook County - Ofgce of Contract Compliance

118 N. ClarkStreet-Rrn 1020Chicago, iL 60602

RE: Contract No. 1455-13763BrRequest for Modification to DBE Utilization Plan —Form 1

Dear Mrs. Moses Potts:

R.M. Chin & Associates, Inc. (RMCA) requests a modification to our original DBE Utilization Plan

to above referenced contract. RMCA was certiged as DBE firm by the City of Chicago in April,

2015.The refme, we respe'ctfully submit our revbed Utilized Plan -Form 1to rellect RMCA asthe DBE Bidder/proposer, along with direct partldpation fi'bm DBE firm, d'Escoto Inc. Please seeattached (Attachment 1) Utilization Plan- Form 1and DBE Letter of Intent- Form 2.

Additionally, please (Attachment 2) find an expianation that provides the assurance the DBE

goals will be met duiing the Amendment 1 period.

Sincerely,

PresidentR.M. CHIN & ASSOCIATES, INC.

APR 2 0 2016

I

'EPARTMENTOP PaocUREMKNT SKRvlcKs

CITY OF CHICAGO

Eileen P. ChinR.IN. Chin & Associates Inc.500 West 18th Street, Suite 200Chicago, IL 60616

Dear Eileen P. Chin:

The City of Chicago has reviewed your annual No Change Affidavit and supportingdocumentation and is pleased to inform you that your firm R.M. Chin & Associates Inc.continues to meet the Disadvantaged Business Enterprise ("DBE"), and AirportConcessions Disadvantaged Business Enterprise ("ACDBE") program certificationeligibility standards set forth in 49 CFR Part 23 & 26. Your next No Change Affidavit isdue Aoril 30. 2017.

This certification allows your firm to participate as a DBE, and as an ACDBE in theillinois Unified CeitNcation Program (IL UCP). The participating agencies include theillinois Department of Transportation, the City of Chicago, the Chicago Transit Authority,Metra and Pace.

If there is any change in circumstances during the course of your certification period thataffect your ability to meet size, disadvantaged status, ownership, or controlrequirements or any material change in the information provided in your initialapplication, you must provide written notification to this agency within thirty'30) daysof the occurrence of the change. Failure to provide this information is a ground fordenial of certification based on failure to cooperate pursuant to 49 CFR 26.109(c).

Your firm's name will appear in the IL UCP DBE Directory under the following categoryname(s):

NAICS Codeisl237110 - Construction management, water and sewage treatment plant237110 - Construction management, water and sewer line237130 - Construction management, power and communication transmission line237310 - Construction management, highway, road, street and bridge237990 - Construction management, dam237990 - Construction management, marine structure237990 - Construction management, mass transit

121 NORTH LASALLK STREET> ROOM 006, CHICAGO, ILLINOIS 60602

R.M. Chin & Associates Inc. Page 2 of 2

237880 - Construction management, outdoor recreation facility237980 - Construction management, tunnel541330 - Civil engineering services541330 - Construction engineering services641330 - Engineering consulting services541340 - Drafting services541360 - Building inspection services541350 - Home inspection services541511 - Computer software analysis and design services, custom641512 - Computer hardware consulting services or consultants541512 - Computer software consulting services or consultants541518 - Software installation services, computer641611 - General management consulting services541611 - Strategic planning consuiting services541820 - Public relations consulting services

The Directory is used by pdme contractors/consultants, as well as other agencies, tosolicit participation of DBE, and ACDBE firma. The Directory can be accessed on theInternet at httc://www.idotil6nois.uov/doino-business/certNcations/disadvantaced-

business-enterorisecertlcation/il-uco-directorv/index.

Vour participation on corrtracts will only be credited toward DBE, and/or ACDBEcontract goals when you perform in your firm's approved area(s) of specialty. Credit forparticipation in an area outside your specialty requires pdor approval (verification ofresources, expertise, and corresponding support documentation, etc.).

Sincerely,

RFirst Deputy Procurement Officer

RB/sl

DEPARTMENT OF PROCUREMENT SERVICES

CITY OF CHICAGO

guL 58 26%

Mr. Frederico d'Escotod'Escoto, Inc.420 N. Wabash, Suite 200Chicago, IL 60611

Dear Frederlco d'Escoto.

The City of Chicago has reviewed your annual No Change Affidavit and supportingdocumentation and is pleased to inform you that your firm, d'Escoto, Inc., continues tomeet the Disadvantaged Business Enterpnse ("DBE")program certification eligibilitystandards set forth in 49 CFR Part 26. Your next No Change Affidavit is due on April 1.~217.

This certification allows your firm to participate as a DBE in the Illinois UnifiedCertification Program (IL UCP). The participating agencies include the illinoisDepartment of Transportation, the City of Chicago, the Chicago Transit Authority, Metreand Pace.

If there is anv rhange in rirrzimstnnrec during the rnurse nf vnur rertificatinn nerind thataffect your ability to meet size, disadvantaged status, ownership, or controlrequirements or any material change in the information provided in your initialapplication, you must provide written notification to this agency within thirty ($0) daysof the occurrence of the change. Failure to provide this information is a ground fordenial of certification based on failure to cooperate pursuant to 49 CFR 26.109(c).

Your firm's name will appear in the IL UCP DBE Directory under the following categoryname(s):

NAICS Code(s)236210 - Construction236220 - Construction237310 - Construction237110- Construction237990 - Construction237990 - Construction

Management, Industrial BuildingManagement, Commercial and Industrial BuildingManagement, Highway, Road, Street and BridgeNlanagement, Water and Sewage Treatment PlantManagement, Mass TransitNlanagement, Outdoor Recreagon Facility

d'Escoto, Inc.

JUL 88 2m6

Page 2 of 2

237880 - Construction Management, Tunnel541330 - Engineering Services541811 - Administrative Management and General Management Consulting

Services541512 - CAD (Computer-Aided Design) Systems Integration Design Services541512 - CAE (Computer-Aided Engineering) Systems Integration Design

Services541980 - All Other Professional, Scientific, and Technical Services541511 - Custom Computer Programming Services541512 - Computer Systems Design Services541619- Other Computer Related Services

The Directory is used by prime contractors/consultants, as well as other agencies, tosolicit participation of DBE firms. The Directory can be accessed on the Internet athtto://www.idot.ilfinois.ac v/doina-business/certiTications/disadvantaced-business-

enterorise-certification/il-uco-directorv/index.

Your participation on contracts will only be credited toward DBE contract goals whenyou perform in your firm's approved area(s) of specialty. Credit for participation in anarea outside your specialty r~uires prior approval (verification of resources, expertise,and corresponding support documentation, etc.).

Sincerely,

First Deputy Procurement Officer

RB/se


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 ChildSupport Obligations, Disclosure of Ownership Interest

and Familial Relationship Disclosure Form

Cook County Affidavit for Wage Theft Ordhance

EDS 1-2

EDS 3 —12

EDS 13-14

Contract and EDS Execution Page

Cook County Signature Page

EDS 15-17

EDS 15

CONTRACT NO. 1455-137638 A1SECTION 1

INSTRUCTIONS FOR COMPLETION OFECONOMIC DISCLOSURE STATEIIIENT AND EXECUTION DOCUMENT

This Economic Disclosure 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 swarded by the County. TheChief Procurement Officer reserves the right to request that the Bidder or Proposer, or Respondent providean 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, Generaf Conditions, Request for Proposals, Request forQualifications, as applicable.

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

Applicant 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 of CookCounty.

Contractor or Contracting Party means a person that enters into a Contract with the County.

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

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

Joint Ventura means an association of two or more Persons proposing to perform a for-profit business enterprise, Joint Ventures must have an agreement in writing specifying theterms and conditions of the relationship between the partners and their relationship andrespective responsibility for the Contract

Lobby or lobbying means to, for compensation, attempt to intluence a County official orCounty employee with respect to any County rnatter.

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 ths 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 sl2015

CONTRACT NO. 1455-137636 A1

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: Ceklflcagons. Section 2 sets forth ceitMcations that are required for contracting parties underthe Code and other applicable laws. Execution of this EDS constitutes a warranty that all the statementsand cerbfications 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 the informationprovided in the EDS is true, correct and complete as of the date of execution, and binds the Applicant tothe wananties, 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, the Applicantshall supplement this EDS up to the time the County takes action, by filing an amended EDS or such otherdocumentation as is required.

Additional Information. The County's Governmental Ethics and Campaign Financing Ordinances imposecertain 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<304 (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, the Presidentand Secretary must execute the EDS. In the event that this EDS is executed by someone other than thePresident, attach hereto a certified copy of that section of the Corporate By-Laws or other authorization bythe Corporation, satisfactory to the County that permits the person to execute EDS for said corporation. Ifthe corporation is not registered in the State of illinois, a copy of the Certificate of Good Standing from thestate of incorporation must be submitled with this Signature Page.

If the Applicant is a partnership or joint venture, all partners or joint venturers must execute the EDS, unlessone partner or joint venture has been authorized to sign for the paitnemhip or joint venture, in which case,the partnership agreement, resolution or evidence of such authority satisfactory to the Office of the ChiefProcurement Officer must be submitted with this Signature Page.

If the Applicant is a member-managed LLC all members must execute the EDS, unless otherwise providedin the operating agreement, resolution or other corporate documents. If the Applicant is a manager-managed LLC, the manager(s) must execute the EDS. The Applicant must attach either a certified copy ofthe operating agreement, resolution or other authorization, satisfactory to the County, demonstrating suchperson has the authority to execute the EDS on behalf of the LLC. If the LLC is not registered in the Stateof illinois, a copy of a current Certificate of Good Standing from the state of incorporation must be submittedwith 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 SIGNATURE PAGESHALL CONSTITUTE A WARRANTY BY THE APPLICANT THAT ALL THE STATEMENTS, CERTIFICATIONS AND INFORMATIONSET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE AND CORRECT AS OF THE DATE THE SIGNATURE PAGEIS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTY LEARNS THAT ANY OF THE FOLLOWING CERTIFICATIONSWERE FALSELY MADE, THAT ANY CONTRACT ENTERED INTO WITH THE APPLICANT SHALL BESUBJECT TO TERMINATION

B.

PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATION

No person or business enfily shall be awarded a contract or sub-contract, for a period of five (5) years from the date of convictionor entry of a plea or admission of guilt, csril or criminal, if that person or buirinsss entity:

1) Has been comiicted of an act committed, within the State of filinois, of bribery or afiempting to bribe an officer oremployee of a unit of state, federal or local government or school district in the Slats of lfiinois in that officer's oremployee's oflidal capacity;

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

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

Has been convicted of an act committed, within the State, of priice-fixing or attempting to fix prices as defined by theSherman Anb-Trust Act and the Clayton Act. 15 U.S.C. Section 1, etseq.;

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

Has been convicted of defrauding or attempting to defraud any unit of state or local government or school district withinthe State of filinois;

3)

4)

7) Has made an admission of guilt of such conduct as set forth in subsections (1) through (6) above which admission is amatter of record, whether or not such person or business entity was subject to prosecution for the offsnse or offensesadmitted to; or

BID-RIGGING OR BID ROTATING

THE APPLICANT HEREBY CERTIFIES THAT: In accordance with 720 ILCS 5/33 E 1 1, neither the Applicant nor any AffiliatedEntity is barred from awanf of this Conlract as a result of s conviction for Ihe violation ofState laws prohibiting bfd-rigging or bidrotating.

8) Has entered a plea of nolo contendere to charge of bribery, 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 enfity may not be awarded a contract if an official, agent or employee ofsuch business entity committed the Prohibited Act on behalf of the business entity and pursuant to the direction or authorizationof an officer, director or other responsible olficlal of ths business entity, and such Prohibited Act occurred within three years priorto the award of the contract. In addition, a business entity shafi be disqualified lf an owner, partner or shareholder controlling,direcfiy or indirectly, 20% or more of ths business entity, or sn officer of the business entity has performed any Prohibited Actwithin five years piior to the award of the Contract.

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

DRUG FREE WORKPLACE ACT

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

D. DELINQUENCY IN PAYMENT OF TAXESEDS-1 8/2015

CONTRACT NO. 1455-13763BA1THE APPLICANT HEREBY CERTIFIES THAT: The Applicant is not en owner or e party responsible for the payment ofany tax orfee administered by Cook County, by a local municipality, or by the illinois Department of Revenue, which such tax or fee isdelinquent such as hsr sward of a contract or subcontract pursuant to the Code, Chapter 34, Section 34 171.

E. HUMAN RIGHTS ORDINANCE

No person who is s party to a contract with Cook County ("County" ) shall engage in unlawful discrimlnation or sexual harassmeraagainst any individual in the terms or condifions of employment, credit, public accommodations, housing, or provision of CountyfaciliTies, services or programs (Code Chapter 42, Section 42-30 et seq.).

F. ILLINOIS HUMAN RIGHTS ACT

THE APPLICANT HEREBY CERTIFIES THATr It ls In con@lienee with the I linols Human Rights Act (775 ILCS 5I2-705), endagrees to abide by the requirements of the Act es part of its contractual ohiigagons.

INSPECTOR GENERAL (COOK COUNTY CODE, CHAPTER 34, SECTION 34 174 and Section 34 250)

The Applicant has not willfully failed to cooperate in an investigation by the Cook County Independent Inspector General or to reportto the Independent inspector General any and all informafion concerning conduct which they know to involve corruption, or othercriminal activity, by another county employee or official, which concerns his or her ofticeMJII00)oymacLor County relatedtransscson.

The Applicant has repoded directly and without any undue delay any suspected or known fiaudulent activity in the County'sProcurement process to the Office of the Cook County Inspedor General.

CAMPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECTION 2%85)

THE APPLICANT CERTIFIES THAT: It has read and shall comply with ths Cook County's Ordinance concerning campaigncontribuhons, which is codified at Chapter 2, Division 2, Subdivision 8, Section 585, and can be read in its entirety atwww.municode.corn,

GIFT BAN, (COOK COUNTY CODE, CHAPTER 2, SECTION 24I74)

THE APPLICANT CERTIRES THAT: It has read and shall comply with the Cook County's Ordinance concerning receiving andsoliciTing gifts and favors, which is codified st Chapter 2, Division 2, Subdivision II, Section 574, and cen bs read in its entirety atwww.municode.corn.

LIVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34-160;

Unless expressly waived by the Cook County Board of Commissioners, the Cade requires that a living wage must be paid toindividuals employed by a Contractor which has a County Contract and by all 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 Financial Officerof the County, and shall be posted on the Chief Procurement Oificer's website.

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

1) Not-For Profit Organizations (defined as 8 corporafion having tax exempt status under Section 501(C)(3)of the UnitedState Internal Revenue Code and recognized under the illinois State nct-for -protlt law);

2) Community Development Block Grants;

3) Cook County Works Department;

4) Sheriffs Work Alternative Program; and

5) Department of Correction inmates.

EDS-2SECllON 3

8/2015

REQUIRED DISCLOSURES

CONTRACT NO 1455-13763BA1

1. DISCLOSURE OF LOBBYIST CONTACTS

List afi persons that have made lobbying contacts on your behalf with respect to this contract:

Name

N/AAddress

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

Local business means a Person, induding a foreign corporation authodized to transact business in illinois, having a bona fideestablishment located within the County at which it is transacting business on ths date when a Bid is submitted to the County, sndwhich employs ths 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 within the County.

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

Yss:X

No:

b) Ifyes, list business addresses within Cook County.

500 West 18th Street, Chicago, LL 60616

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

Yss: No:

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

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

All Applicants are required to review the Cook County Affidavit of Child Support Obligations attached to this EDS (EDS-5) andcomplete the Atfidavit, based on the instructions in the Affidavit

EDS-3 5/2015

CONTRACT NO. 1455-137638A14. REAL ESTATE OWNERSHIP DISCLOSURES.

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

a) The following is a complete list cf afi real estate owned by the Applicant in Cook County:

PERMANENT INDEX NUMBER(S):

(ATTACH SHEET IF NECESSARY TO LIST ADDITIONAL INDEXNUMBERS)

OR:

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

5. EXCEPTIONS TO CERTIFICATIONS OR DISCLOSURES.

If the Applicant is unable to certify to any of the Cerfifications or any other statements contained in this EDS and not explained elsewhere inthis EDS, the Applicant must explain below:

If the letters, "NA', the word "None" or "No Response'ppears above, or if the space is left blank, it will be conclusively presumed that theApplicant certified to afi Certificafions and other statements contained in this EDS.

EOS-4 8/2015

CONTRACT NO. 1455-13763BA1

COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT

The Cook County Code of Ordinances (I2-610 et serf.) requires that any Applicant for any County Action must disclose informationconcerning ownership interests In the Applicant. This Disdosurs of Ownership Interest Statement must be completed with all informationcurrent ss of ths date this Statement is signed. Fudhermcre, this Statement must be kept current, by filing sn emended Statement, until

such time as the County Board or County Agency shall take action on the application. Tha information contained in this Bslement will

be maintained in a database and made available for public viewing.

If you are asked to list names, but there are no applicable names to list, you must state NONE. An incomplete Statement will be returnedand any action regarding this contract will be delayed, A failure to fully comply with ths ordinance msy result in the action taken by theCounty Board or County Agency being voided.

"Applicant" means sny Entity or person making an application to the County for any County Action.

County Action" means any action 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" "Enf/Iy or "Legal 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 Interest Statement must be submitted by:

1.An Applicant for County Action and

2. A Person that holds stock or a bsneilclal Interest in the Applicant ggd is listed on the Applicant's Statement (a "Holdeg must file aStatement and complete gt only under Ownership Interest Declaration.

Please pdint or type responses clearly and legibly. Add additional pages if needed, being careful to identify each portion of the form towhkdi each additional page refers.

This Statement ls being made by the [ X ] Applicant or [ ] Stock/Beneficial Interest Holder

This Statement is an: [ X ] Original Statement or [ ] Amended Statement

Identifying Information:

Name R.M. Chin 8r Associates, ]nc.

D/B/A:

Street Address:

City Chicago

Phone No.; 312-595-2000

FEIN NO 363631821

State:

Fax Number; 312-644-0999Zip Code: 60616

eileen'mch]n. corn

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-6 8/2016

Ownership Interest Declaradon:CONTRACT NO. 1455-137638A1

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

Name Address Percentage Interest In

Applicant/Holder

Eileen Chin ]42] South Emerald Avenue, Chicago, IL 60616 5]%Ravmond Chin 100East Huron. Chicago. IL 60611 49%

Ifthe interest of any Person listed in (1) above is hald as sn agent or agents, ore nominee or nominees, list the name andaddress of the pdincipal on whose behalf the interest is held.

Name of Agent/Nominee Name of Principal Principafs Address

I sthe Applicant consbuctively controlled by another person or Legal Entity? ]Yes [ X ]NoIfyes, state the name, address and percentage of benefidal interest of such person, and the relationship under which suchcontrol is being or may be exercised.

Name Address Percentage ofBenegcial Interest

Relationship

Corporate Officers, Membem and Partners Information:

For all corporaaons, list the names, addresses, and terms for all corporate officers. 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 perkier/joint venture)

Term of Office

Eileen Chin 1421 South Emerald Avenue, Chicago, IL 60607,President, ChairofBoard, Officer

Raymond Chin: 500 W. IgthStreet, Chicago, IL 60616,Officer

Annual

Annual

Declaration (check the applicable box):

[ X] I state under oath that ths Applicant has withheld no disdosure 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 CountyAgency action.

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

EDS-7 8/2015

CONTRACT NO. 1455-137638 A1

COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT SIGNATURE PAGE

R.M. Chin 5I Associates, Inc. /Eileen ChinName of Authorized

'r Representative (please print or type) Tise

Signature / Date

eileencgrmdnn.corn 312-961-1564E-mail address Phone Number

Subscdibed to and sworn before methis

APIra-dayof~we.,20'otary

Public Signature

gy Ccromianlnn ~r'FFICIALSEAL

AHN T HORVATH

Hotsry Public - Seas sl illinoisrr Snit

NotlSlr'SIIIII""'""

EDS-8 8/201 5


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

CHICAGO, ILLINOIS 60602312/603-4304 Office 312/603-99$$ Fax

FAMILIAL RELATIONSHIP DISCLOSURE PROVISION

Nenotism Disdosure 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 any municipalitywithin the County. The Ethics Ordinance defines a significant amount of business for the purpose of this disclosure requirement asmore than $25,000 in aggregate County leases, contracts, purchases or sales in any calendar year.

Ifyou are unsure ofwhether the business you do with the County or a County agency will cross this threshold, err on the side of caution

by completing the attached familial disclosure form because, among other potential penalties, any person found guilty of failing to makea required disclosure or knowingly filing a false, misleading, or incomplete disclosure will be prohibited Rom doing any business with

the County for a period of three years. The required disclosure should be filed with the Board of Ethics by January 1 of each calendaryear in which you are doing business with the County and again with each bid/proposal/quotation to do business with Cook CountyThe Board ofEthics may assess a late filing fee of $100 per day ager 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 fi om or selling to the County is a business entity, then the business entity must disclose the familial relationships

of the individuals who are and, during the year prior to doing business with the County, were:

~ its board of directors,~ its ofEcets,~ its employees or independent contractors responsible for the general administration of the entity,

~ its agents authorized to execute documents on behalf of ihe entity, and

~ its 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 familial

relationship disclosure.

Additional Definitions:

"Famiffa/ relationship" means a person who is a spouse, domestic partner or civil union partner of a County employee or State, Countyor municipal official, or any person who is related to such an employee or oIIIcial, whether by blood, marriage or adoptioa, as a;

t3 ParentCj ChildCl Brother0 SisterCl AuntCJ Uncle0 NieceCl Nephew

t3 Graadparent0 GrandchildD Father-in-lawCJ Moiher-in-law

Cl Son-in-law0 Daughter-in-lawCl Brother-in-law

CJ Sister-in-law

0 Stepfather0 Stepmother0 Stepson0 Stepdaughter0 Stepbrother0 Stepsister0 Half-brother0 Half-sister

EDS-9 8/2015

CONTRACT NO. 1455-13763A ATCOOK COUNTY BOARD OF ETHICS

FAMILIAL RELATIONSHIP DISCLOSURE FORM

A, .PERSONJDOINOOR.SKEEING.TO DO BUSINESS WITH THK COUNTY.,

Name of Person Doing Business with the County,'AR gn CktlBu. I I"'0:5'lfREST '4'7 %8%~a-0'55 u <i «.'4l

Address ofPerson Doing Business with the County: 5()() W. ~%'5 SPCe4 '4 r4 > 5 f-hi Ez>eRE~OO(t>l(t>.Snf

Phone number ofPerson Doing Business with the County" 5 )8l ~VS ..4k+-tz)r()--

Email addressof Person Doing Business with the County:;.Kt !<Ant 8 fgsvcL I ~ ..C,0thn .--—IfPerson Doing Bminess with the County is a Business Entity, provide the name, title and contact information for the individualcompleting this disclosure on behalf of the Person Doing Business with the County:

DESCRIPTION OF BUSINESS WITH THE COUNIYAppend additional pttges as needed dnd for each County lease, contract, purchase or sale sougltt andlor obtainedduring the calendar year ofthis disclosure (or the proceeding calendar year ifdisclosure is mmle on January I),identify:

The lease number, contract number, purchase order nuinber, request for pmpossl number and/or request for qualificationnumber associated with the business you are doing or seeking to do with the County;

C.OAkr,> Ab. 1 "(55-13'7f.)E

The aggregate dollar value of the business you are doing or seeking to do with the County: ) 5f 5. 00 () ——

The name, title and contact information for the County cIHcial(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 oBicial(s) or employee(s) involved in tnanaging the business you arcdoing or seeking to do with the County:

XRgcL..QU~S44$ax, Mf«k. FEc ftt f= .M0>, 5'f'Rtaut: >a.,(k.~4lr Its t.C. DISCLOSURE OE.FAMILIAL RELATIORSHIPS qgIEIT.HIIT)(EEq(t EM>~4'>FAH(HL@515>ltPY. QN,;

,XtUNICIPXK'KLXCTKD Dg'EICIALS,

Check the boz that applies and provide related information where needed

The Person Doing Business with the County is an individual and there is ne familial relationship between this individualand any Cook County employee or 'any person holding elective office in the State of Illinois, Cook County, or anymunicipality within Cook County.

The Person Doing Business with the County is a business entity and there is no familial relationship between any memberof this business entity's board ofdirectors, ofHcers, persons responsible for general administmtion 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, an'd inly Cook County employee or any person holding elective ofHce id the*State of El(nots, Cook County, or any municipality within Cook County.

EUS-10 8/2015

CONTRACT NO. 1455-137638 A1COOK COUNTY BOARD OF ETHICS


A. 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 ofPerson Doing Business with the County:

Email address of Person Doing Business with the County:

IfPerson Doing Business with the County is a Business Entity, provide the name, title and contact information for the individualcompleting this disclosure on behalf of the Person Doing Business with the County:

Eileen Chin, President of R.M.Chin gr Associates, Inc. 312-595-2000 or eileenc(prmchin.corn

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

The lease number, conuuct number, purchase order number, request for proposal number and/or request for qualificationnumber associated with the business you are doing or seeking to do with the County:

Contract No. 145-13763B

The aggregate dollar value of the business you are doing or seeking to do with the County: $ 515 .cttszr

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: Xart q ster'S"ra r' ir %ta'va tr ta 2.c~ surrau~ ~<

qc~aor tc. Sra"az.~ ~e"l OqrA c-~r ~ t m~i~c n SsS.vain ~s rI 1 v" trts~+l484 I a+, ra< tR o uoo csvicstc.o z~ sacer~

I

The name, title and contact information for the County oflicial(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

i3 The Person Doing Business with the County is an individual snd there is no familial relationship between this mdividualand any Cook County employee or any person holding elective office in the State of Illinois, Cook County, or anymunicipality within Cook County.

KX The Person Doing Business with the County is a business entity and there is no familial relationship between any memberof this business entity's bomd 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

CONTRACT NO. 1455-13763BA1COOK COUNTY BOARD OF ETHICS


0 The Person Doing Business with the County is aa individual and there is a familial relationship between this individualand 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 ofRelatedEmployee or State, County or County Employee or State, CountyMunicipal Elected Otficial or Municipal Elected Oificlal

Nature ofFamilialRelationship"

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, ofiicers, persons responsible for general administration of the businessentity, agents authorized to execute documents on behalf of the business entity and/or employees directly engaged incontractual 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 of Member ofBoardofDirector for BusinessEntity Doing Business withthe County

Name of Related County Title and Fosition ofRelatedEmployee or State, County or County Employee or State, CountyMunicipal Elected Otficial or Municipal Elected Oilicial

Nature of FamilialRelationship*

Name of Oificer for Business Name of Related County Title and Position of Related Nature of FamilialEntity Doing Business with Employee or State, County or County Employee or State, County

Relationship'he

County Municipal Elected Otficial or Municipal Elected Otficial

EDS-11 8/2015

Name ofPerson Responsiblefor the GeneralAdministration of theBusiness Entity DoingBusiness with the County

CONTRACT NO. 1455-137636A1Name ofRelated County Title and Position of Related Nature of FamilialEmployee or State, County or County Employee or State, County

Relationship'unicipal

Elected OIEcial or Municipal Elected OIEcial

Name of Agent Authorized

to Execute Documents forBusiness Entity DoingBusiness with the County

Name of Related Couniy Title and Position of Related Nature ofFamilialEmployee or State, County or County Employee or State, County

Relationship'unicipal

Elected OIEcial or Municipal Elected OIEtial

Name of Employee ofBusiness Entity DirectlyEngaged in Doing Businesswith the County

Name of Related County Title and Position of RelatedEmployee or State, County or Couaty Employee or State, CountyMunicipal Elected OSicial or Municipal Elected OIEcial

Nature of Familial

Relationship'f

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

VERIFICATION: To the best ofmy knowledge, the information I have provided on this disclosure form is accurate and complete. Iacknowledge ate or incomplete disclosure is punishable by law, includingtbut n9t limited to fines and debarment.

PPv/~uSignature oP(ecipient Date

SUBMIT COMPLETED FORM TO: Cook County Board of Ethics69 West Washington Street, Suite 3040, Chicago, Illinois 60602Office (312)603-4304 —Fax (312)603-9988CookCounty.Ethicscookcountyil.gov

'pouse, domestic partner, civil union partner or parent, child, sibling, aunt, uncle, niece, nephew, grandparent or grandchild

by blood, mamage (i.e. in laws and step relations) or adoption.

EDS-12 8/2015

CONTRACT NO. 1455-137636A1SECTION 4

COOK COUNTY AFFIDAVIT FOR WAGE THEFT ORDINANCE

E//ective Msy 1, 2015, every person, inc/udino Subsssugsi Owners, seeking a Contract wilh Cook County must comply with the Cook County Wage TheOrdinance set faith In Chapter 34, Arude IV, Section 179. AnY person/Substantial Owner, who fails to comply wiui Cook County Wage Theft Ordinance marequest that the Chief Procurement Ofilcer grant a reduction or waiver ln accordance with Secuan 34-179(d).

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

"person" means any individual, corporation, partnership, Joint Venture, trust, association, limBed Babiiity company, sole proprietorship or other legal enfity

"Pracursmenr means obtaining supplies, equipment, goods, or services of any kind.

"Substsnt/si Owner" means any person ar persons who own or hold a twenty-five percent (25%) ar more percentage of interest In any business entity seeklna County Privsege, including those shareholders, general or limited partners, beneficiaries and principals; except where s business entity is an individual <sole proprietorship, Substantial Owner means that individual or sole proprietor.

All persons/Substantial Owners aie required to complete this affidavit and comply with the Cook Caunty Wage Thelt Ordinance before any Contract is awards<Signature of this form constitutes a certification the information provided below is correct and mmplete, snd that the individual(s) signing this form has/hsvpersonal knowledce of such informauon.

I. Contract Information:

No. 1455-13763B

County I/sing Agency (requesfing procurement): DePartment of Planning gtDeveloPment

II. Person/Substantial Owner Information:

Person (Corporate Entity Name): I( M Chin 5/ Associates, Inc.

Substantial Owner Complete Name:Eileen Chin

FEIN¹

Date of Birth:

Street Address: 1421 South Emerald Avenue

Chicago

Home Phone; ~312 961-1564

III. Compliance with Wage Laws:

p I dd, eileencermchin.cornE-mail address:

State:

Driver's License No:

zip. 60607

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

illinois Wage Psymenf and Collection Acf, 820 ILCS 11&1etseq., YES or gii/inois Minimum Wage Acf, 820 ILCS 105/I el seq., YES or IQO

li/inois Worker Atgusfmenf snd Re/ra/ning Notiflcstion Act, 820 ILCS 65/I el seq., YES or j(jOO)

Employee C/ass/float/a Act, 820 ILCS 185/1 et ssq., YESor~FairLabor Standards Act of1938, 29 (/SC. 201, et ssq., YES or 0

Any comparable s/s/e s/atu/e or regu/alion of any state, which governs the payment of wages YES otalIf the Person/Substantial Owner answered "Yes"to any of the quesfiions above, It is ineligible to enter into a Contract with Cook County,but can request a reduction or waiver under Section IV,

EDS-13 8/2015

CONTRACT NO. 1455-13763EIA1

IV. Request for Waiver or Reduction

If Person/Substantial Owner answered "Yes" to any of the questions above, it may requests reduction or waiver in accordancewith Sechon 34-179(d), provided that the request for reduction of waiver is reads on the basis of one or more of the followingactions that have taken place:

There hss been a bona fide change in ownership or Control of the ineligible Person or Substantla/ OwnerYES or NO

Disciplinary action has been taken against the indivtduaf(si responsible for the acts giving rise to the violationYES or NO

Remedial ection hss been talrsn to prevent s Iscunence of the acts giving rise to the disquslillceffon 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 suooori the basis ofits reauest for s mduct/on or waiver The ChiefProcurement Deicer reserves the rioh to make edditionslinaulrlss and rsaueat add//fons/ dacumenlslion.

V. AffirmationThe Person/Substantial Owner aff I Iatements contained in the Aflidavit are true, accurate snII,coypPte.

Signature: D.~: dJA'//0'ir'ame

of person signing <print[: Eileen Chin Tjget PreSident

S bscribed a sworn to before me this ran 4'ay of ZUd I'./et

X

,20 Zd

-INotary Public Signature Notary .'uTr

Note: the above information ls subject to veriffcstfon prior to the awanf of the conti tct. 0FFIGIAL SEAL

AHN T HOIIVATH

Hdary public - Stats ui Nineia

yat Ouataauffuu Expires gac 8.201T

EDS-14 8/2015


Cf)QK CQ~FIDAVIT-IIQIL %AGE TBXIIT ORBINANGE,.

8'ffsctivifitfaayi f5, every frsrson, fiibhrdcrss~'~~'aroufifrtfkfsstisiiiifii505frttjprriust comply with thrrefhfit figu)I@)fu~ordirisnce set forth in Chapter 34,~'Np~e)58ISL Any psrscigSu5idsrittaj owner, krha fskv to comply whh Gook county wage Thett 0'nfinahmr, ms

'equest that the Chief Plccuremsnt OScer giant e redusfian ci irttivsr in acaardanci with Secficn 34AY5(d).

"conintcl" means sny wrlttlrn document ta make prscuwrtents by or on behalf of cock County.

"person" means any individual, corporation, partnership, Joint Venture, trust, association, limksd I'ability company, sole praprietorship or other legal enNy;

"Pmcuremsnf'eans obtaining supplies, equipment, goads, or services of any kind.

"substantial owner'esne sny person or parsons who cwn or hold s twenty<vs percent (25'I ) or more percentage of kiterest In any buslnsfis In(tty sseklna County Privilege, Inclufilrlg tltose shareholders, general or llmitlild partners, hsneficlprlss snd principals; accept where s business entity is an Individual csale proprietorship, substsrrtlsl Owner'mesne thatt iridivktvsi arable prapdslor.

All personslgubslantial owners amtsquired ta campksa this s'ffidavit snd camply with the Gook County Wage ThstlOrdinancs befam any Contract ls awarder'ignature of ibis farm constitutes a certification the infimnsticn provided balaw is canect and complete, snd thstfiw individual(s) signing this form hsalhsvfiuAieiteNIf~of such~,

Contract Infbrq)ation:

Contract Number:

County Using Agency (requssfrng Procurement):

II. personlsubstantial owner Informatlonp

person (Corporate Entity blame)5, R M. (-httt 8r Associates, Ittc.

Substantial Owner Complete Name,'..Q.-tkftk~

FEIN¹

E-mail address: /"MzmdtD~Date of Birtltf

Street Addressk

Home Phone: ~'44Fv;.'~ - -. --. "--:, Driver's Licensef)jfgL

gl. Compliance with Wage laws:

City

Within the past fwe years Itas the Person/Substanfiat Owner, in any judicial or admktistrative proceeding, been convicted of, entered aplea, made an admission of guilt or liability, or had en administrative finding made for committing a repeated or willful viobdion of any ofthe following laws:

¹gnois Wage Payment snd Colleclion Acf, 820 ILC$ 115ff ef saq., YES~illinois Nl'nimum Wage Ac'I, 820 ILCS f0'f seq., YES od

Iginois Wbrksr Arffusfmenf snd Retraining Nofificslion Acf, 820 ILCS 65rf ef seq., YES o

Empioyse clsssllfca0on Acf, 820 ILcS 18&I sl ssq., YE8 ogEafr Labor Standards Acf of 1938, 29 ILS.C.201, sf ssq., YES d~Any coinpsrsbls state shrtute or regulation of any stats, wfrfch governs the payment of wages YESo

lf the person/Substantla) Owner answered "Yes"to any of tha questions above, It is Ineligible to enter into a Contract with Cook County,but cfin request a reduct)on or waiver under Secgon IV.

EDS-13 8/201 5

CONTRACT NO. 1466-137636A1SECTION 4

COOK COUNTY AFFIDAVIT IrOR WAGE THEFT ORDINANCE

Efiective Msy 1, 2015, every Person, /nc/udina Subskmfis/ Owners, seeking a Contract with Cock County must comply with the Cook County Wage TliwOrdinance set forth in Chapter 34, Arttde IV, Section 179. Any person/Subsurntlal Owner, who falls to comply with Cook County Wage Theft Ordinance, marequest that the Chief Procurement Officer grant a reduction or waiver in sees/dance with Section 34-179(d),

"Con/reef'eans any written document to make Procurements by or on behalf of Cook County.

"person" means any individual, cwporstion, partnership, Joint Venture, trust, association, limited liability company, sole propriietorship or other legal enrity.

"Procuiemsnf'eans obtaining supplies, equipment, goods, or services of any kind.

"Substsnl/s/ Owned means any person or persons who own or hold a twenty-five percent (25%)or mors percentage of Interest In any business entity sesklna County Privilege, including those shareholders, general or limited partners, beneficiaries snd principals; except where a business entity Is an Individual rsole 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 Contract is awarderSignature of this form constitutes a cerÃication the information provided below is correct snd complete, and that the individual(s) signing this form has/havpersonal kncvrisdos of such information.

I. Contract Information:

Contract Number.

County Using Agency (requesting Procurement):

II. Parson/Substantial Owner Information:

Person (Corporate Entity Name):

Substantial Owner Complete Name:

363631821

R.)VL Chin tjr Associates, Inc.

Date of Birth:

Street Address:

City: cA~4

Home Phone: ~4 5'& ivies&

III. Compliance with Wage Laws:

State: ~iDriver's License NoiL

ZiP: ds corCci v /

MrE-mail address: t 4 Pain&/r ~~i&~ ~~M

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

///inois Wage Payment and Collection Act, 820 ILCS 115/I etseq.,

ii/inois Minimum Wage Act, 820 /LCS 105/I et ssq., YES orgg//i/no/s Worker Adjustment and Retraining /Vol/fica/ion Act, 820 /LCS 85/1 et seq., YES or~Employee C/sss//Ics//on Act, 820/LCS 185/1 et seq., YES orgQ

Fair Labor Stsndan/s Act of 1938, 29 U.S.C.201, et seq., YESo~Any comparable state statule or regulation o/any stats, which governs the payment o/ wages YES

oQNN'f

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

EDS-13 8/2015


IV. Request for Waiver or Reduction

If Person/Substantial Owner answered 'Yes" to any of the questions above, it may request a reduction or waiver in accordancewith Section 34-179(d), provided that the request for reducgon of waiver is made on the basis of one or more of the followingactions that have taken place:

There has been a bone fide change in owners/ilp or Control of the ineligible Person or Substantial OwnerYES or NO

Disciplinary action has been taken against the /ndividual(s) responsible for the eels giving rise to the violationYES or NO

Remedial action has been taken to prevent a recunsnce of the acts giving rise to the d/situs/ificst/on or defaultYES or NO

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

The Person/Substantial Owner must submit documentation to suoooit ths basis ofils rscuest for e mductlon or waiver. The Chic/Pmcurement Otffcer reserves the rloht to make additional lnouliles and ieousst addihonel documentation.

V. AffirmationThe Person/Substantial Owner affirms that sll statements contained in the Allidavit are true, accurate and complete.

Signature: Oats: Pi~~lr~Name of person signing (print): A stusw~ Whim Title: ~aM~Sub 'bed and sworn to before me this W2 day of v//i'/I W, 20'

Notary Public Signature Notary'eal N"" i~mr. sklttNote: The above information is subject to verification Prior to the award of the Co /act. ENsi iq

'ATH+ - SIsN ot INsNs"o iss gsc 8, 2QI 7

Nli Com/s/sales EkplI~i

EOS-14 8/2015

SECTION 5CONTRACT NO. 1455-137638 A1

CONTRACT AND EDS EXECUTION PAGEPLEASE EXECUTE THREE ORIGINAL COPIES

The Applicant hereby certifies and warrants that all of the statements, certlflcations and representations set forth in this EDS are true,complete and correct; that the Applicant is in full compliance and will continue to be in compliance throughout the term of the Contract orCounty Privilege issued to the Applicant with all the policies snd requirements set forth in this EDS; and that sll facts snd information providedby the Applicant in this EDS are true, complete and correct. The Applicant agrees to inform the Chief Procurement Officer in writing if any ofsuch statements, certifications, representations, fetus or information becomes or is found to be untrue, incomplete or incorrect during theterm of the Contract or County Privilege.

R.M. Chin &Associates, Inc.Corporation's Name

3212-595-2000

Telephone

Secretary Signjeturs

Execution by Corporation

Eileen Chin

President's Printed Najfe and Signature

[email protected]

~I~/(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

Data Telephone and Email

Execution by Sole Proprietorship

Printed Name and Signature Date

Telephone Email

Subscrgted and sworp to before ms thisQ P'~ day oAJI/e (,20'�. I

iMy commission expires:

OFFICIAL SEAL

ANN T HORVATH

Notary Public - State al llbnaia

My Carsmieeiaa Explree Oec 8, 20t I

Notary Public Signature Notary Seal

If the operating agreement, partnership agreement or governing documents requiring execution by multiple members, managers,partners, or joint venturers, please complete and execute additional Contract and EDS Execution Pages.

EDS-17 8/2015