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Contract No. 1664-1 5226 Amendment No. 1
Vendor Name: URT E & R TOWING, INC. 0/B/A XPERT TOWiNG & REPAIR
AMENDMENT NO. 1
This Amendment modifies Contract No 1684-15226, for Maintenance, Repair, Parts & Labor for Buses and Heavy DutyTrucks (Zone 1) by and between the County of Cook, illinois, herein referred to as County" and URT E & R Towing, Inc.
d/b/a Xpert Towing & Repair, authorized to do business in the State of Illinois hereinafter referred to as "Contractor ':
RECITALS
Whereas, fhe County and Contractor have entered into a Contract approved by the County Board on October 26, 2016,(hereinafter referred to as the "Contract"), wherein the Contractor is to provide Maintenance, Repair, Parts & Labor for Busesand Heavy Duty Trucks (Zone 2) (hereinafter referred to as the "Services" ) from December 1, 2016 through November 30,201 8, with two, one year renewal options, in an amount not to exceed $351 400 00; and
Whereas, E 8 R Towing 8, Garage, Inc. d/b/a Xpert Towing & Repair advised the Office of the Chief Procurement Officerthat it changed its name to URT E 8 R Towing, Inc. d/b/a Xpert Towing & Repair on and now operates under the name URT
E & R Towing, Inc. d/b/a Xpert Towing & Repair; and
Whereas, an increase in the amount of $1 45,000.00 is required for the continuation of Services; and
Now therefore, in consideration of mutual covenants contained herein, it is agreed by and between the parties to amend theContract as follows:
1. The obligations of this Contract are hereby transferred to URT E & R Towing, Inc. d/b/a Xpert Towing & Repair.
2. As per Section IB-26, Notices, Section GC-24 General Notice, a8 notices required to be sent to URT E & R Towing,Inc. d/b/a Xpert Towing & Repair is revised as follows:
URT E & R Towing, Inc. d/b/a Xpert Towing & Repair16325 S. Crawford Ave.
Markham, IL 60428
3. The Contract is increased by $145,000.00 and the Total Contract Amount is revised to $486,400.00.
4. The attached Identification of Sub-Contractors/Suppliers/Sub-Consultants Form, MBE/WBE Utilization Plan formsand Economic Disclosures Statement under Attachment A are incorporated and made a part of this contract.
5. 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 lastwritten below.
Chief Procurement Officer
D.t'. (4JItNC S«S
ByState's Attorney (if applicable)
Type or print name (if applicable)
D 1, W)&Rev 6/lrl7
URjP'& /Towing, Inc. d/b/a Xpert Toviing and Repairf~rc~Signed
K:.tov',~ Cmr c'~r a DType or print name
C~~Title
D.t.:
Contract No. 1684-1 5226 Amendment No. 1
Vendor Name: E & R TOWING & GARAGE, INC. DIB/A XPERT TOWING & REPAIR
ATTACHMENT A
aev 6(tn7
CONTRACT NO. 1664-16226
Cook County OGPO ONLY:
Office of the Chief Procurement Officer A tl'h/ii 'szsassani
Identfftcation of Subcontractor/Supplier/Subconsultant Form ~! w .(f3 Ohszkyfsrddtste
The Bidder/Proposer/Respondent ("the Contractor") will fully complete and execute and submit an Identification ofSubcontractor/Supplier/Subconsultant Form ("ISF") with each Bid, Request for Proposal, and Request forQustgca(ian. Ths Contractor must complete the ISF for each Subcontmctor, Supplier ar Subconsultant whichshall be user( on the Contract. In the event that there are any changes in the uti/ization af Subcontractors,Suppliers or Subconsultants, the Contractor must file an updated ISF.
BN/RFP/RFQ No „1684-15226
Total Bid or Proposal Amount
contractor. URT E&R Towing, Inc.
Authorized Contactfar Cantrscton Kevin Corcoran
(can IracIaf }k C Or C Or 6n un iIedrO6dtOWin0 COm
Email Address k
C Addr 16325 S. Claw/old Ave
(Contrsdor):
& "(c „~N r) Markham, IL 60428
(Cant/suer) 708-333-7300 708-333-7324
Estimated Start andI Campletian Dates TBD
(Canlrsctor}
Date:5/1/18
ContmctTitle iww~~ ivrwr~iiiv as M iH w! D trTN Its/zweu
Subcontractor/Supplier/Subconsultant to be Black Dog Petroleumadded .or substitute:Authorized Contact for
i Subcantractor/Supplier/Amit GauriSubcansultsnt:
nk &,), [email protected] Address
', Company Add~a 2305 EnterPrise Drive
!'Subcontractor):
', City, State snd ZiPwestchester, IL 60154,"(Subcontractor):TelePhone and Fax 708-562-4400 706 562~04,,(Subcontractor)
'stimated Start and'ompletion Dates TBD
{Subcontractor)
Note: Upon request, s copy of sll written subcontractor agreements must be provided ta ths DCPD.
t)sacr)agan.ofServtase angtmolhre
Petroleum and petroleum products
Total Price ofSubcontract for
Services or:Buon)les
314,500.00
The subcontract documents will incorporate all requirements of the Contract awarded ta the Contractor ss applicable.The subcontract will in no way hinder the Subcontractor/Supplier/Subcansultant from maintaining its pmgress an anyether cantraci on which it is either s Subcontractor/Suppfier/Subcansultsnt ar principal contractor. This disclosure ismade with the understanding that the Centractor is nat under any circumstances relieved of As abilities snd obligations,and is responsible for ths organization, performance, and quality of work. This form does not approve any proposedchanges, revisions or modifications to the contract approved S/IBE/WBE Utilization Phn. Any changes to thecontract's approved MBE/WBE/Utiltzatlon Plan must be submitted ta the Office of the Contract Compliance.
URTE&R Towing, Inc.ContractorNaun r nate nranName'.!~eris/el hiahanor,
cPrime Cantractar Signature
SA JeDate
I SF-1 July/2016
CONTRACT NO. 1664-15226
Cook County 'iniCPLOV ONLY;
Office of the Chief Procuremsnt Officer , A ~otsiuikMcegrih 'dentlflcationof Subcontractor/Supplier/Subconsultant Corm
The Bidder/Proposer/Respondent ("the Contractor") will fully complete snd execute and submit an identification ofSubcontmctor/Suppter/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 bs 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 I SF.
Sld/RFP/RFQ N,, 1684-15226
Total Bid or Pmocsst Amount "5145,000.00
Contractor: URT E&R Towing, Inc.
Authorized Contactfor Contractor Kevin Corcoran
kcorcoran(iunitedroadtowing.corn
Company Addmss 16325 $ . Crawford Ave
(Contractor):
Date: 5/1/18
iContractTit)e'uaeenenc,R w,p h xkstarlara ndwmoulyr k izon 2l
'Subcontractor/Supplier/Subconsultant to be G&E Sales Corpadded er substituteAuthbnzed Contact forSubcontractor/Supplier/ Judith LubinSubconsu!tant:Small Adt/res's:ISubcentfttdter) Illiegetruckparts.corn
, Company Address13856 S. Heisted St.: „(Subcontractor):
''..& ."
.), Markham, IL 60428~ZI CcMrasMC)i
(W~o )T08 333 T300 708 333 7324
Estimated Start andCompletion Dates TBD(Con'trsttor),
Telephcrie'and Fsx708 841 1895 "/08 841 2075tsttbocntrebtor)Eabmated Start sndCompletion Dates TBD(Subcontractor)
Note: Upon request, a copy of ail written subcontractor agreements must be provided to the OCPO.
thmcribffon of Services.or:Stmdflmi
Truck parts and supplies, repair and replacement of hoses
Total.Prhs dt'.
Subcontrsetfkirsermons or Suenlies.
$14,500.00
The subcontract docuinents will incorporate all raqqgsmsnta ofthe centmct'awarded to:ule'contractoras ttppliceb)e.The subcontract will in no wsy hinder the Subocihttm)bf/Spppllirlgdbconsuftiint'fmm maintaining its progress on, anyother contract on which it is either a Subcqgf)Peter/Supplier/Suhcranegfhfrit ',Ot Pt(nc(Pat.~C, Th)sukgsdtcsure ismade wiih the understanding that the'Contridfer is not heifer a'y clicumstancesmllevsd of its abilibssand obligsiiohs;and is responsiblefor theorganization, petfqnnaffes, and quallt)/of vfsi)t, This form dkisa not appreveany pmpossdchanges. rekrls/ons.or'modlffcadons to ths'c'ontriact appmved MSE/WBE Utilization Plan. Any changes to thecontract's approved MBEIWBE/Utilization Plan must be submitted to the Office of the Contract Compliance.
URT E&R Towinq, In,cContractorKevin CorcoranName6'enerdf'Msnegey.
Prime Contractor Signature&i» I)V
Date
ISF-1 July/2016
OFFTOE GF eONTRACT COMPUANCE
JAC'4MEUME rhOMEZ
OIRECTEHL
ttsFA cfotk eoontfr Building, Roomlc20 ~ Chfooso, Illinois 606os e t312) so3-55e2
TOESE'tsttadrttsltNIKE
PRESIDEhn
eoofseooosl snoreor ettnvnfosfonors
RIEHARD R. BQYIGH
1st Dfstriit
DENNIS DEER
2ntf Dlshto
Ms. Shannon E.. Andrews
cMef proeffrelnent ctgcerCounty Buildiog-.Rcom 1015
Chicago, IL $0502
Re: Contract Ne. tgtt4 15225 (Amsrtdmsnt N'D. 1)
Maintenance, Repairs Pads 5 Laber fer Buses.snd Heavy Duty Trucks (zone 2)
Department ofTrsnspcltsbcb and Highways
JERRY BDTLER
shpoutntt
STANLEY hterQRE
Oth Dhtrltt
DESORAH SINS
5th Dtstnst
EQYYARD sfl. hfrJODY
6th Drstnrt
JESUS e. GAflOA
7th District
Dssr h!E Andreset
The Office of Contrast Compliance M in receipt of the, above-referenda eontraot amendment and has revievrad it
for compliance ttft(h tha Minetfty- and (kfprpfe- ottfned Bgsiness Entergdses (MBE(WBE) Ordinance. Jkfhhr Careful
rsv(EFEY, it has been defennined tliis antdndrnent ia nmp'onsive to.tlat ortgnanbe.
Bidder URT E tt R Totssrig, Ibc,.dba)(baft'Tbwrng 5. Repair
Original Contract Amount; $551,4000ig
increased Corltmct )aslue: $145t000:00 (Amendment Nth 1)
New Contract Value: $455,400.00
Ceeksct Bosk l0% MBE, 10% WBE
LLES ARROYO,JR
8th District
PETER N. QLVESTRI
9th Dlitrlrt
Eel DGET GANT R
10th Dlslnd
Slack Dog Chicago Carp„dbaSack Dog Ch(sago, LLC
8 (t E Bales C'orp.
Cartthrlnnno
City ofChicagoCity efChicago
Cornrnitntenk(Direct)'goyo
fg-'yo
JOHSLP.DAtEY
11th Dlslrltl
JOHN A sulTCHEY
12th Dlstnirn
LEERY SUFFREDIN
tsth DJSnlra
'COmmitment Pereentageerere tfaaed On the neW CcfdraetVatue
Originsl MBEJwBE forms were used in the dstmminaimn Df tits responsiveness Df this ccnksct.
Sincerely,
GRESG GOSUN
14th District
TIEIOTHY O. SCHNEIDER
15th Dlstria
JEFFREY R. TOSOLSJC
16th Dfstrlst
SEAFI H HOSLSCH
17th Dlstrlrt
Ccnlraei Compliance Director
JGfm
cc: i Barbie Flock, OCPO
Nicki Cannatsllo, DOTH
Randy PiscMi, DOTH
I() Fistsf Responsibility f Innovative Leadership fer Transparency at Jtrceotrntnrlifity Qstw tmprcved services
CONTRACT NO. 1664-16226
BIDDER/PROPOSER HEREBY STATES that sll MBE/WBE firms inc)uded in Ibis Plan are certified MBEs/WBEs by at ieusi ons of the entities listed in the GeneralConditions — Section 19.
I. BIDDER/PROPOSER MBE/WBE STATUS: (check the appropriate line}
Bidder(Proposer is a certifwd MBE or WBE finn. (If so, attach copy of current Letter cf Certification}
'Bkf/(elipfc} obiir is a Jffi(fi yfhn((as i@4fmaoampfs/3~venture Bfitbtsrs are datfgfkd MBEs or WBBb, {If so, attach copies Bf~ of
,'~Phr'adsdyy dfJbfnt y@ilF(s~&Cfebjfy'dgfidbing thbfidihrof the M~'finn(s} sndbsonr ershio interest m IIWI}ffinbtfrfnhirseblis~ Jold,'}/ebb/ns'it~~ oojiigr stwnwkuudreodnbrsnsii~
Bidder/proposer is not a certified MBE or WBE firm, nor s Joint Venture with MBE/WBE partners, but vali utilize MBE and WBE fans eitherdirecily or indirectly in the periorm ance of the Contract (If so, complete Sections II below and the Letter(s} of Intent - Form 2}.
lt„~g Direct Panlclpation of MBE/wBE Firms~I}
"i Indirect Participation of MBE/wBE Firma
FMyfdr„",.Where go/dg By'fivaiftufbestf achleyuff 'tbrofyglI'dirdpygbrttclPat to'n ijgjtbbdfpfhgpstir shall include dbattmsti(a6'on rmtfflaing tfffgrts tofch(il'vi Direct piit6ts'ttagonuaNieilme of~ldutj /nifubion. Indftsuif~db will only be coafskfdebdiit@ialt effs/fjaftyachieveDirect partlcipatjoii have bean exhausted. Only after written documentation of Good Faith Efforts is rectiived wig Indirect parliclpation beconsidered.
p..:.. -.,708-562-4400
MBEs/WBEs that will perform as subcontractors/suppliers/consultants include the following'.
65/n/6F FIim8 Iaok Do9 PetroIauIn
, 2305 Enterprise Drive, Vyastchaeter, IL
@, arnit(nbfackdogpatrolaum
co I~p „, Amit Gauri
Dufiar Amount Participation; $
10/PsrcentAmountofParficipakon:=- %%d
*Loner cf Intent attached? YesX
No*Currmt Latter of Certification attached? Yes X ........, —. Nb
mE Saies Corp.
13656 S. Halsted St., Riverdala, IL 60827
j Il@getruckparts . corn
JudithLubin, .. 708-841-1995
Dofisr Amount PanicipationuS,$49,640.00
, 10%Percsnt Arriount cf Participation:
1.sitar ol Intent afiached? Yss No."CunsntLettw of Ceriification attached? Yas X No
Attach~ sheets es needed.
*Letter(e) of Intent and current Letters of Certification must be submitted at the time of bid.
M/VVBE Utilization Plan - Form 1 Revised.01/29/2014
COttTRACT NQ. 168$.15226
SSBEAIBSG'LBTTER22P.'BNKMITii".INSR88.2,.
~E F. Black Dog Petroleum City of ChicagoM/WBE Fimr ..— =-.- . -= Cerfriying Agency:
Cmlact Parscnt.Amil Gauri ..... 11/22/2022
Csrsficsgon Expiration Dale:
Address:2305 Enterprise Drive
Bhnkly:Asian American
astcheale2
LBkgp ~ ks 8
1 684 1 5226
706-5624400 708-5624404 82-171302'B
E Iarnlttg)blsckdogpetrolsum
Email:
Psnlcipagon: Irr) gimel ( j Indimct
Will the M/WBE gnn bs subconlracling any of Ihe goods or services of ibis contract to another finn1
( x j No ( j Yes- Please sltsch explanation. Propomd Subcontractor(s);
The undesigned M/WBE is prepsmd lo provide the following Commodges/Services for the above named Pmjecy Contract (I/
xum xpscs n needed m /sxydsrcdhe IslvBE plank pmpvxsd xrqpe v/ rwrh snider ps/resnl xchsddlx, sltscrr sikeM xhserr)
Petroleum and pshoieum products,.lubricants & wholesale suppgss.
Indicate ths gagas&maaaB~snd lhe TaNi&g~for the abave dsxcribed Comma%as/Services;
549,640,00 10'Yv Dt/R nel 10 days
THE UNDERSiGNED PARTIEB AGREE srst Sris Leltwof Intent will becomes binding Subcontract Agreement for the above work,amdgoned upon (1) Ihs Bddtu/Propose/s Isceipi of a signed canlrsct gom Ihs caunly of cook; (2) Undsrskpsd subcontractor
Signsksa (hf/WBE)
Amit Gauri
Pnnt Name
Black Dog Petroleum LLC
'bP)((r)Name
"'
& R Towing and Garage, Inc.
mmainlng'
sli relevant credengals, codes, ordinsnom and statutes requimd by Contractor, Cook County, snd theStateto, MBE/WBE Srm for Ihs above work. Ths U d
'P li d I rtily thsllhey dkl not elfin their
, eel until sll areas under Descriptio ofSs completed..
ssr)
Fikm Name
04/1 8/2018
Dkte
Subscribe snd swnm befommerp/-
this /rr/vt/ ri)jl5/G 20~/
()L (I)Nalsry Pubth
.,imam
~~
I 'PPICIALSEALI GRSGORV M GOETTKE I
', f Ill)acts r,
"4, 281 g
F'ii"I
[i
Dale ".I
Subsoibed and swam before me
dris &4dWBf D~"ANotsryPublic. Alike . Sxj.y
nussc - slate sl lnincix Revised; 1/25/tesion Sxpirev Jvx
DEPARTMENT OF pROCOREMENT SERVICES
CITY OF CHICAGO
JAjlj12 2(}18
Mr. Amit GauriBlack Dog Chicago Corp2305 Enterprise DriveWestchester, IL 601 54
Dear Amit Gauri:
The City of Chicago has reviewed your annual No Change Afildavit and supportingdocumentation and is pleased to inform you that your firm, Black Dog Chicago Corp,continues to meet the Disadvantaged Business Enterprise ("DBE"j, and AirportConcessions Disadvantaged Business Enterprise ("ACDBE"j certification programeligibility standards set forth in 49 CFR Parts 23 & 26. Your next No Change Affidavit isdue November 1. 2048.
This certification allows your firm to participate as a DBE, and as an ACDBE in thelliinois Unified CertÃication Program (IL UCP). The participating agencies include theCity of Chicago, illinois Department of Transportation, the Chicago Transit Authority,Metre 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 notiTication 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 26.1 09(c},
Your firm's name wiii appear in the IL UCP DBE Directory under the following category
name(s}'AICS
Codels):424120 - Paper, Office (e.g., carbon, computer, copier, Typewriter} Merchant
Wholesalers424690 - Cleaning Compounds and Preparations and Allied Products and Other
Chemical INerchant WholesalersITI NeRTR LAsALLasTREET;:ROOM ~fircAdb", BiLINSIs~
Black Dog Chicago Corp ~01K?IH() Page 2 of 2
424720- Gasoline, Fuel Oil, Crude Oil, Petroieum and Petroleum Products;Liquefied Petroleum Gas, Oil, Petroleum, Lubricating Oils and Grease(except build stations and terminals); Merchant Wholesalers; Fueling AirCraft (except on contract basis) and Fuel Oil Truck Jobbers
722310 - Airline Food Services Contractors722320 - Catersrs7225t3 - Fast Food Restaurants
The Directory is used by prime contractors/consultants, as well as other agencies, tosolicit participation of DBE, and ACDBE firms. The Directory can be accessed on theInternet at httos;/twebaribs.dc%Illinois oov/UCBIBxternafgesreh.
Your paiticipafion on contracts 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 prior approval (verification ofresources, expertise, and corresponding support documentation, etc.).
Sincerely
Rich BugerFirst Deputy Procurement Officer
RB/cm
CONTRACT NO. 'I 664-I 5226
„MBE/yyBE LETTER OF INTENT - FORM 2
kt/I/IBEF[fmi 'Q, I f', "+[BE Cot p,, cenifymgAgency. PA»: Af...~4, ilr
CcntaotParxon:, ~kI/k -1 ~kiln&. = ., Certrfioeticn'~ Deke ....[ l b'uL&
Address:.... [Mm[rr ....duv Hat[&4 SJ Ethnicity:~
City/Stats: Gt[EIB[skl+, pL Zip [ndr8Ãt Btd/Proposa¹Contmct¹:
Phone: M%4W[i"Niff Fax 7CC¹5N,"-W5'EIN ¹:
Emait . Lthi4'BtEJEVWkAty+ cw trk,i
Pargctpation: [)I[ Diced t /indirect
trtliit Ihs kryyyBE firm be eubconlracfing any of the goods or services of this contract to another finny
T)[LNo [ )Yss- Please attach explanation. Proposed Subcontitctor(s):".
The undersigned IJ/WBE is prepared to provide the following Commodities/Services fcr ths abave named Project/ Contract /ifewe arccc seceded tc luliy dcccche M/IVSE Fmc'c prcpcxcd /mope cr wurk ccd/cr peymmrr schedule, rdrcch cddirmncr sheen/
Truck parts and supplies, repair and replacement ol hoses
Indicate Iheitbr[)arAnttsanb Psfbiinbfga, and ths Terms of Payment for the shove described Commodities/ Services:
$49,840.00 10% DUR net 10 days
ramsintng compliant with e relevant credentials, codes, ordinances and statutes required by Contractor, Cook County, and theStats to participate as a IJ BWBE firm for the above work. 'fhe Undersigned Parties do also certily that they crid not affix theira@natures to Ibis documsn nlil sll areas under Dascnption of '!i, FsefCost were completed,
~Zcehk .L. L.hrm ..Vie:~ WxcvuurPrint Name
P +p E & R Towing and Garage, Inc.
Finn Name Firm N~+SO 12 8k)i'Bll'b
Subscribed snd sworn bstore meI
lais l~dayrd -jkrrgkrir c '[ . 20 l+fy'nm4 A...o-
Notary Public.~kulLB
M/WSE Letter of Intent - Form 2 Revised: 1/29/14
Subscribed enCh~;before me
;.2o „.LkaeXNotary Public -.(~ )tvt:N
OffICIAL 99ALCHBIVL J NCBINE
Nalary Psbtto - Stela af ggnelsIgy consnlssioa Expir¹4 Jen 4. 26I9
THE UNDERSIGNED PARTIES AGREE that this Letter of Intent Millbeco me a binding Subccnlracl Agreemsnt fw the above work,conditioned r¹ron [I) the Bidder/Proposer's receipt of a signed consent ttom the county of cook, [2) Undersigned subconlractor
Jf}}} } 8 gp}}}
DIIRRI"re~Iver lIP Paoon"Rtrasias SRRv IRRR
CITY 0 P 0 II I CRII0
Judith L Lubin5 &,E Sales.GorporatlonI 6666 S. HeistedItivsrdsts; iL BGB27
Dear Judith L. Lubin:
VIIS are pleaaed tO infOrm.yOu that Cv B O Salsa gprpsratlbn has been reCertified aa aayemen-Osnted Sqafrtass IzsWiMie,txtftSN".}:btl Ots Qdy. Of S}I}sago WOy'}, ",Athr»OSS ~onIS VRNO 4!l Aft»fggi»f htsraaiir,,}ICRI}::Orrf}tva.bardgpri4dh fifutd .ISI ORVa»dated SIInpaity. In thePSSOOIRCOIOf h&'PROV»fbd yPS tat»tan'Sttrisat )Stall~'trout'alWlgaatfbfg,agdh ldgettraiS
"bi tstntsRL,,W 8 ooftsetttfsf»srtts'@loxf w'@ho even sdtlsc gjjirtt frr '4rsf yotirottnf@t fftpbhshgsdsftcofrrs40 ttdoo BNIOIO:Osur annIIBt-anniversary date.
lt fa ndw. ysor tsspdh@ffiftr ts
Rheo}tost
'@oyrs:~dn ofltxftcio sect veftfy yodr dsrt5asfrensfaftas A'a'8 bboctlosri 4} continued'st»FI»soph dbfthg ofd fttsossar- osrtbd tttdtod dtxhsh youmtad Ole an attltuafN~ Artffdavtt. Y+f Orbit}aithsal NO4ihlttge PSSSRIS fardue Oyffdgfggtg, Oifgfggge ii'e»lyly Orig tie»SO»It. IRSraaa remember; OOI .haVS Sn afffrmsbuidutyrti Ofs your Seve gs, AfftdsvSBO cblys„prior to the dais of expiration: 'FRNur's to tile yourannual N5chahgs Pdoddvo fnoy rsaUB OI ths dtlapehsion sr'ssotssisn ol your csrtlfication,
'fcsrr»tlofa Itqs*ossr osft»fsaodhvvtllitN»tfg en 4/4»I}too}f. Yso hsvs an attfmiaoos dotLI to ffisfav oteetISsioion B'0 rds}}to oriov,tcr tl»r tottsi of 48 ootpfssr gnrttvsssaty dat». Thshsfffre, youmust tffe fbr,r'soertSR'etton by C»f4t»20»L
lt ls Iryfppemt.to nots ttidt you goto baser an oh»sing slllrmatsrj;rfuoi ta nbof}f ofi coyqpfrshybhangea fn 0'rnerehfP'r eentIOIOf ybgr ftrtrtr, Oy Srtyr dther 'faotaSS xgngysur Onfra SIIOOOSO farCRSOtidsffqn fatthttr, 'll}'SS}f'erof Surehfgtanfter i~i, ' '
tftfgr Indtuda OIO Sr» not Ond d tO
8 OII»nga Of add&sea,,'Often»a .ef:: buxaiiaSS Strutdure;, e lh qsipafahip Or OWneralilpRtruetuiah chihge of business Opeisopnar gross. Isssttdgrshd oy prfteohat nat worth that sxoesdthe jrogfsm'thtfrshold. Fstlurti'toprrsvicts tha Coy vrlthWOIII ratios of'such eharsos may resultln Ih8'tapen»fqn Or reatcbginn Of, ybur Cefttffbatient ln gdl}IOO@ you may be liable fOr Civil
Oanrdtfdagntfey chagfeF1W, "FsfSSClairrrrf rtll»tofddntsff'art Cbdtstg'Cfllsagsv
pfassshats = yod,sttsll }ye deemed to have hao your certificatio lapse and'BIII bs.ineligible lotxrd&yats aa 8 Wss if }fou Ag:toc
File your snriual, No-Change Affidavit within the required time psrlbd;p'resets financis'1 or other records requested pursuant Io an audh within the required timepsIIod;
IXI IvDIITH LA'SAL'„K 'Srisr!ET, ROOM. BIIC, CHICA(,'II II;: INrIIII 0000R
p
G'& E Sales Corporation Page 2 of 2-4 tttottfy the, city of any changes iitfacting your firm's certihcation within 10 days of such
change; or4, File your recertificaticn within Ihe required time period.
pissse ba iapthided df yottrcbptrastuaf ob)ft)Stion to:np))palate vt)th ths,ctty,gfgb rssgsfd gt ahy~. tttggfb or:~abdb!Sf )lb.bo~ and a)Tire ~p grp)thsgtb ',iyp~'gge'yeitto:a~u)t tnt~tpt)'t)ar'~of our~8)rsgpbrgrtg'~ orsr:.~Brtbb~')Ilg~ senora) i'bteiiiio)bspstdbbtpntsral dfg,
or 88848-TIPLIhtE f888&48&754).
'Be-advised ithat if'you or your firm 'is found to be involved'in csrtifica)ion, bidding ahd/orcontractual frauci or abuse, the City'will pursue decergfication and debsrmens in addition to anyOfhbr pfrnagy Jinp'cibsg'by Jaw,;;anypernpn sdte krtca)Ngty obtains„„or Irnostftgly aeabfs,.anothertn: Obta)hing a,.deribgbt Si)th,:thev Q)ty'bvyq falaiily:rbPrbgtiijHntt:Iha ttdttrtdu)d Or entity, Or theIndlgtduat:or entity as'ilsted brj'utlty. of8)rib@a)nbanoi, punishable by ln'carasration in the countyJail for a period riot to exceed'six months, or a fins of not less than 85,000 and not more than810,000 or both.
Your firm's name will be listed in the City's Directory of Minority 'Srtd Women-Owned BusinessEntsrprises in the specialty area(s) of:
iyAICS Cadets):423120 Motor vehicle parts and accessories, new, merchant sihblesalers
Your firm'8 participation On City contracts will be credited only,bntrard Itfwnan~19sNypietae t)aahii In'bgfaiabttt)gpscislty. w'hils your psitislpsillon en c))y contracts
fs ptttt)in)tad:to ybui 81%la,afspsda)ty, prsrgt~ goals w(1, IN'given only for whiff that ts Sstf.per)or)bed and prov)ding.a oemmere)ally IISS)rd,ftmotion that i )8 dqistr, ln tbs. anprotied speigh)tycategor'y.
yhttrtfcystgfer ybgr litters'in tt)8.CIJJ))'gi~ 'Wornehgg,trafec Bits)ness Entegrrise, Veteran-Buhhtppg E~e brt)I 8~ Bntetpr)ap .o'wnsd -or operated try peopte with
Oissbi ities (MBEJWBEAIBE/BEPD) Program.
Bincerel
p)rgt Deputy procurement (ÃicerRBrag
CONTRACT NO. 1684-15226
PETITION FOR REDUCTION/WAIVER OF MBE/WBE PARTICIPATION — FORSI 3
A. BIDDER/PROPOSER HEREBV'RE{3UESTS:
FULL MBE WAtVER FULLWBEWAIVER
REDUCTION (PARTIAL MBE snd/or WBE PARTICIPATION)
% of Reduction for MBE PSR/cfp@IOD
% of Reduction for WBE Pi/ltdP'atloii, NOT APPLICABLE
B. REASON FOR FULL'/REDUCTION WAIVER REQUEST
Bidder/Proposer shall check each item applicable to its reason for a waiver request. Additionally, supportingdocumentation shall be submiNed with this request.
(I) Lack of sufficient qualified MBEs and/or WBEs capable of providing the goods or services required
by the contract. (Please explain)
(2) The specifications and necessary requirements for performing the contract make it impossible oreconomically infeasible to divide the contract to enable the contractor to utilize MBEs and/or WBEsin accordance with the applicable participation. {Please explain)
(3) Price(s) quoted by potential MBEs and/or WBEs are above competitive levels and increase cost of
doing business and would make acceptance of such MBE and/or WBE bid economicaliyimpracticable, taking into consideration the percentage of total contract price represented by suchMBE and/or WBE bid. (Please explain)
(4) There are other relevant factors making it impossible or economically infeasible to utiiize MBE
and/or WBE firms. (Please explain)
C. GOOD FAITH EFFORTS TO.OBTAIN MBE/WEE IvARTICIPALTION
(1) Made timely written solicitation to identified lvlBEs and WBEs for utilization of goods and/orservices; and provided MBEs and WBEs with a timely opportunity to review and obtain relevant
specifications, terms and conditions of the proposal to enable MBEs and WBEs to prepare aninformed response to solicitation. (Attach of copy written solicitations made)
(2) Used the services and assistance of the Office of Contract Compliance staff. {Please explain)
(3) Timely notified and used the services and assistance of community, minority and women businessorganizations. (Attach of copy written solicitations made}
(4) Followed up on initial solicitation of MBEs and WBEs to determine iffirms ars interested in doingbusiness. (Attach supporting documentation)
(5) Engaged MBEs & WBEs for directlindirect participation. (Please explain)
D. OTHER RELEVANT'INFORISATfON
Attach any other documentation relative to Good Faith Efforts in complying with MBE/WBE participation.
M/VVSE Reduction/VVeiver Request - Form 3 Revised: 01/29/14
CONTRACT NO. 1684-15226
EXHIBIT VllCOOK COUNTY
ECONOMIC DISCLOSURE STATEMENTAND EXECUTION DOCUMENT
INDEX
Section Description
Instructions for Completion of EDS
Paces'
I
EDS i - ii
Cert1Tications
Economic and Other Disclosures, Affidavit of ChildSupport Obligations, Disclosure of Ownership Interest
and Familial Relationship Disclosure Form
Cook County Aflidavit for Wage Theft Ordinance
Contract and EDS Execution Page
Cook County Signature Page
EDS 1-2
EOS 3-12
EDS 13-14
EDS 15-'! 7
EDS 18
CONTRACT NO. 1684-15226
SECTION 1
INSTRUCTIONS FOR COIIIPLETION OFECONOMIC DISCLOSURErSTJLTFjWENT frt5ID. EXECUTION.DOCUNIENT
This Economic Disclosure Statement and Execution Document ("EDS") is to be completed and executed by everyBidder on a County contract, every Proposer responding to a Request for Proposats, and every Respondentresponding to s Request for Qualifications, and others as required by the Chief Procurement Officer. The executionof the EDS shall serve as the execution of a contract awarded by the County. The Chief Procurement Officer reservesthe right to request that the Bidder or Proposer, or Respondent provide an updated EDS on an annual basis.
Definitions. Terms used in this EDS and not otherwise defined herein shall have the meanings given to such termsin the instructions to Bidders, General Conditions, Request for Proposals, Request for Qualifications, as applicable.
Afffffete means a person that directly or indirectly through one or more intermediaries, Controls is Controlledby, or is under common Control with the Person specified.
Applicant means s 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 indude any written document to make Procurements by or on behalf of Cook County.
Contractor or Contracting Party means s person that enters into s Contract with the County.
Controi means the unfettered authority to directly or indirectly manage governance, administration,work, snd sli other aspects of a business.
EDS means this complete Economic Disclosure Statement and Execution Document, including allsections listed in the Index and any attachments.
Joint Venture means an association of two or more Persons proposing to perform a for+refitbusiness enterprise, Joint Ventures must have an agreement in writing specifying the terms andconditions of the relationship between the partners and their relationship and respective responsibilityfor the Contract
Lobby cr lobbying means to, for compensation, attempt to influence a County official or Countyemployee with respect to any County matter.
Lobbyist means any person who lobbies.
Person or Persons means any individual, corporation, partnership, Joint Venture, trust, association, LimitedLiability Company, sole proprietorship or other legal entity.
Profrlbited Acts means any of the actions or occurrences which form the basis for disqualificationunder the Code, or under the Certifications hereinafter set forth.
Propossi means a response to an RFP,.
Proposer means a person submitting a Proposal.
Response means response to sn 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-1 March/2017
CONTRACT NO. 1684-15226
INSTRUCTIONS FOR CONIPLETION OFECONOIIIIIC 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 conkacting parties under theCode and other applicable laws. Execution of this EDS constitutes a warranty that all the statements andcertifications contained, and all the facts stated, in the Certifications are true, correct and complete as of the dateof execution.
Section 3: Economic and Other Disclosures Statement. Section 3 is the Count)rs required Economic sndOther Disclosures Statement form. Execution of this EDS constitutes a warranty that all the information providedin the EDS is true, correct and complete as of the date of execution, and binds the Applicant to the warranties,representations, agreements and acknowledgements contained therein.
Required Updates. The Applicant is required to keep all information provided in this EDS current and accurate.In the event of any change in the information provided, including but not limited to any change which wouldrender inaccurate or incomplete any certification or statement made in this EDS, the Applicant shallsupplement 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 impose certainduties and obligations on persons or entities seeking County contracts, work, business, or transactions, and theApplicant is expected to comply fully with these ordinances. For further information please contact the Director ofEthics at (312) 603-4304 (69 W. Washington St. Suite 3040, Chicago, IL 50502) or visit the web.site atcookcountyil.gov/ethiceboard-of.
Authorized Signem of Contract and EDS Execution Page. If the Applicant is a corporation, thePresidentand Secretary must execute the EDS. In the event that this EDS is executed by someone other than the President,attach hereto a certified copy of that section of the Corporate By-Laws or other authorization by theCorporation, satisfactory to the County that permits the person to execute EDS for said corporation. If thecorporation is not registered in the State of illinois, a copy of the Certificate of Good Standing from the state ofincorporation 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, unlessone partner or joint venture has been authorized to sign for the partnership or joint venture, in which case, thepartnership agreement, resolution or evidence of such authority satisfactory to the Office of the Chief ProcurementOfficer must be submitted with this Signature Page.
If the Applicant is a member4nanaged I.LC all members must execute the EDS, unless otherwise providedin the operating agreement, resolution or other corporate documents. If the Applicant is a manager-managedLLC, the manager(s} must execute the EDS. The Applicant must attach either a certified copy of the operatingagreement, resolution or other authodization, satisfactory to the County, demonstrating such person has theauthority to execute the EDS on behalf of the LLC. If the LLC is not registered in the State of illinois, a copy of8 current Certificate of Good Standing from the state of incorporation must be submitted with this SignaturePage.
If the Applicant is a Sole Proprietorship, the sole proprietor must execute the EDS.
A "Partnership" fJoint Venture" or "Sole Proprietorship" operating under sn 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.
Effective October 1, 2016 all foreign corporations and LLCs must be registered with the Illinois Secretary of State'Office unless a statutory exemption applies to the applicant. Applicants who are exempt from registering mustprovide a written statement explaining why they are exempt from registering as a foreign entity with the illinoisSecretary of State's Office.
EDS-2 March/2017
CONTRACT NO. 1684-15226
SECTION 2
CERTIFICATIONS
THE FOLLOWING CERTIFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE. THE APPLICANT ISCAUTIONED TO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE. SIGNING THESIGNATURE PAGE SHALL CONSTITUTE A WARRANTY BY THE APPLICANT THAT ALL THE STATEMENTS,CERTIFICATIONS AND INFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE ANDCORRECT AS OF THE DATE THE SIGNATURE PAGE IS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTYLEARNS THAT ANY OF THE FOLLOWING CERTIFICATIONS WERE FALSELY MADE, THAT ANY CONTRACT ENTEREDINTO WITH THE APPLICANT SHALL BE SUBJECT TO TERMINATION.
A. PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATION
Na persan or business entity shall be awarded a contract or sub-contract, for s period af five (5) years from the date ofconviction or entry of a plea or admission af guilt, civil or criminal, if that person or buwiness entity:
1) Has been convicted of an act committed, within the State of Illinois, af bribery or attempting to bribe an officeror employee of a unit of state, federal or local government or school district in the State af filinois in that officer'or employee's official capacity;
2) Has been convicted by federal, state or local government of an sct of bid-rigging ar attempting to rig bids asdefined in the Sherman Anti-Trust Act and Clayton Act. Aat. 15 U.S.C. Section 1 el seq;Has been convicted of bid-ngging or attempting to rig bids under the laws af federal, state or local government;
Has been convicted of an act committed, within the State, af price-fixing or attempting ta fix prices as delinedby the Sherman Anti-Trust Act and the Claytan Act. 15 U.S.C. Section 1, sf sequHas 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 districtwithin the State of illinois;
3)
4)
5)
6)
7) Has made an admission of guilt of such conduct ss set forth in subsecfions (1) through {6) above whichadmission is a matter of record, whether or nat such peisan or business entity was subject to prosecution forthe offense or offenses admitted to; or
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 casa of bribery or attempting to bnbe, a business entity may nat be swarded a contract if sn offfcisl, agent oremployee of such business entity committed the Prahibited Act an behalf of the business entity and pursuant to thedirection or authorization of an officer, director or other responsible afficial af the business entity, and such Prohibited Actoccurred vrithh three years prior to the award af the contract. In addition, a business entity shall be disqualified if anowner, partner or shareholder controlling, directly ar indirectly, 20'A or more af the business enbty, or an afiicer of thebusiness entity has performed any Prohibited Act within five years prior to the sward of the ContrackTHE APPLICANT HEREBY CERTIFIES THAT: The Applicant has read the provisions of Section A, Persons andEntities Subject to Disqualification, that the Applicant has not committed any prohibited Aat set forth in Section A, andthat award of the Contract to the Applicant would not violate the provisions of such Sscban sr af the Code.
B. BIDJUGGING OR BID ROTATING
THE APPLICAIVT HEREBY CERTIFIES THAT: In accordance with 720 ILCS 5/33 E-1 1, nellher Ihs Applicant nor anyAh'llialed Enfily ls barred from award of this Contract as s result of s convlcfian for lhe violation of State laws prohibitingbid-rigging or bid misting.
DRUG FREE WORKPLACE ACT
THE APPL(CANT HEREBY CERTIFIES THAT: The Applicant will provide a drug free workplace, as required by (30 ILCS580(3).
EDS-3 March/2017
CONTRACT NO. 1684-15226
D. DELINQUENCY IN PAYMENT OF TAXES
THE APPLICANT HEREBY CERTIFIES THAT: The Applicant is nol an owner or a party respona'tile for the payment afany lax or fee administered by Cook County, by a local municipality, or by the lilinois Lkrpartment of Revenue, which suchtax or fee is delinquent, such as bar award ofa contract or subcontract pursuant to the Cods, Chapter 34, Section 34-171.
E. HUMAN RIGHTS ORDINANCE
No person who is a party ta a contract with Cook County ("County") shall engage in uniawful discnmination or sexualharassment against any individual in the terms or conditions of employment, credit, public accommodations, housing, orpravisian af County facilities, services or programs (Code Chapter 42, Section 42-30 et seq.).
F. ILUNOIS HUMAN RIGHTS ACT
THE APPLICANT HEREBY CERTIFIES THAT: It is in compliance with the illinois Human Rights Act (TT5 ILCS Srgd05),and agrees lo abide by the requirements of the Act as part ofits contractual obligations.
G. INSPECTOR GENERAL (COOK COUNTY CODE, CHAPTER 34, SECTION 34.174 and Secuon 34-250}
The Applicant has not willfully failed ta cooperate in an investigation by the Cook County Independent Inspector General orta report to the Independent Inspector General any and all information concerning conduct which they know to involvecorruption, or other criminal ectivity, by another county employee or afficial, which concerns his or her office of employmentor County related transaction.
The Applicant has reported directly and without any undue delay any suspected ar known fraudulent activity in the County'sProcurement process to the Office of the Cook County Inspector General.
H. CANIPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECTION 24I85}
THE APPLICANT CERTIFIES THAT: It has read and shall camply with the Cook County's Ordinance concerning campaigncontributians, which is codified at Chapter 2, Division 2, Subdivision 8, Section 585, and can be read in its entirety stwww.municode.corn.
GIFT DANI (COOK COUNTY CODE CHAPTER 2 SECTION 24I74)
THE APPLICANT CERTIFIES THAT: It hss read and shall camply with the Cook Caunty's Ordinance concerning receivingand saiiciting gifts and favors, which is codified at Chapter 2, Division 2, Subdivisian 8, Sectian 574, and can be read in itsentirety at.www.municadelcom.
LIVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34-180;
Unless expressiy waived by the Cook County Board of Cammissianers, the Cade requires that a living wage must be paidto individuals emplcyed by s Contractor which has a Caunty Contract and by all subcontractars of such Contractor under aCounty Contract, throughout the duration of such County Contract. The amaunt of such living wage is annually by the ChiefFinancial Dtficer 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 cantracts with the fallowing:
1) Nat-For Profit Organizations (defined as a corporation having tax exempt statue under Section 501(C)(3) of theUnited State Internal Revenue Code and recognized under the Illinois State not-for 4rrofit lsw);
2) Community Development Block Grants;
3) Cook County Works Department,
4) Sheriff's Work Alternative Program; and
5) Depatunent of Correctian inmates.
EBS'arch/2017
CONTRACT NO. 1684-15226
SECTION 3
RE UIREB BIBCLGBIJRES
1. DISCLOSURE OF LOBBYIST CONTACTS
List all persons thol have made lobbying contacts an your behalf with respect to this cantracb
Name
NoneAddress
2. LOCAL BUSINESS PREFERENCE STATEMENT (CODE, CHAPTER 34, SECTION 34-236)
Lacal business means a Persan, including a foreign corporation authorized to transact business in illinois, 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,and which employs ihe majority of its regular, full-time work force within the County. A Jaint Venture shall constitute a LocalBusiness if one or more Persons that qualify as a "Local Business" hald interests tataling aver 50 percent in the Joint Venture,even if the Jaint Venture does not, at the time of the Bid submittal, have such a bona fide establishment within the County.
a) Is Applicant s "Lacal Business" as desned above?
Yes:X
b) If yes, list business addresses within Cook County:
16325 S. Crawford Ave, Markham, IL 60428
129 N, Heisted St., Chicago Heights, IL 60411
c) Dace Applicant employ the majority of its regular full-time workforce within Coak Caunty?
Yes: X Noi',
3. THE CHILD SUPPORT ENFORCEMENT ORDINANCE (CODE, CHAPTER 34, SECTION 34-1?2)
Every Applicant for a County Privilege shall be in full compliance with any child support order before such Applicant is entitled toreceive or renew a'County Privilege. When delinquent child support exists, the County shall not issue or renew any County Pdivilege,and may revoke any County Privilege.
Ag Applicants ere mqutred to review the Cook Caunty Affidavit of Child Suppart Obligations attached to this EDS (EDS&)and complete the Afgdavit, based on the instructions in the Affidavit.
EDS-5 starch/2017
CONTRACTNQ. 1684-15226
4. REAL ESTATE OWNERSHIP DISCLOSURES.
The Applicant must indicate by checking the appropriate provision below and providing ag required information that either.
a) The foyowing is a complete list of ag real estate owned by the Applicant in Cook County:
PERMANENT INDEX NUMBER(S):
(ATTACH SHEET IF NECESSARY TO LIST ADDITIONAL INDEXNUMBERS)
OR:
Xb) The Applicant owns nc real estate in Cook County.
6. EXCEPTIONS TO CERTIFICATIONS OR DISCLOSURES.
If the Applicant is unable to certify to any of the Gertificagons or any other statements contained in this EOS and not explainedelsewhere in this EDS, the Applicant must explain below;
NA
If the letters, "NA', the word "None" or "No Response" appeam above, or if the space is leR blank, it will be conclusively presumedthat the Applicant cerfified to all Certiftcations and other statements contained in this EDS.
EDS-6 March/2017
CONTRACT NO. 166 4-15226
Zip Code: 60 28
Fma,i kCarCOran(g)ulfitedrOad[OWing.aam
COOK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATE(SENT
The cook county code df Drainsness (62-616 el aea. ) mqulred that any Appliciit foi any county Aclian must disdoae information'ancamlng wvnwship interesls In the Applicant, This Oisdosure of Ownemhip fnterest Statement must be completed with afi'nfarmatian cunent ss of the dais this St«lament ii signed. Furthermore, this Statement must be kept current, by Sing an.'amended, Statement„ungl such time as the County Beard or County Agency shall take action on the Spplicafian, The information contained [n.this Statement wiN be makrtstned [n s database and rrmde available far public vtewtng. County reserves the right ta mquest
'dditional infarmagon to vargy ihe veracity of informsgoo contained in this statement.„, If yau am asked ta fist names, but there are no applicable names to list, you must state NONE. An Incomplete Statement will be'; returned and any eagan regarding this contract will be db(ayed. A failure to fully comply with the ardinance may result in tire action
taken by the Caunty baaed or County Agency being vafr((svg,
"Applicanl" means sny Entity or peraan making an applicatian to the County for any Coun(y Action.5Caunfy Aahht", nfesim.sny action by a 'Ca))hty Agency, a County Department, or the Caunty Beard regarding an ardinsnce arttrd[hance tmtendrttsf)E a County Board Epl[iiyal, or other County agency approval, with respect to cantrscts, leases, or sale or
[, purchase afreatestate."Parson" "Entify'r "Legal Enlily" means a sole praprietarship, carparation, partnership, assaclalian, business trust, estate, two or
more persons having a [aint ar camman internet, trustee of s land lrust, ether commercial ar legal entity or any benetlciary orbeneficisrles thereof.
This Oisdasure afQwnership interest Statement must be submitted by:1. An Applicant far Caunty Acfian and2. 'Sfyfiiiisjin that halds stock wa,~ intdipfd;:in the
r'cant.'figg[r[tvtisted an the Applicant's Statement (a "Ifofder" I must file a
Stp[gggtptand complete «1 only unvdiiiihw'nsrfg([hvtnmrsa'bmlamgfttt,Please pnni aysftltt~'c(fisdy and legibly. Aod additional pages if needed, being careful ta identibr each parson of ths form to
'hich each ddd[tk)dst',fxgye'ffigtmx
This Statement la being made by the [ x [ Applicant or [ )stock/Beneficial Interest fielder
This Scatsmsnt ls an. [ x )Original Ststementor ( [Amended Ststemenl
ldentgyiag lnfannstiant
Name URT EBR Towing, Inc,
D)hhk xpsd Towing and Repair FEIN «only 82 128060
Street Agdtefist 16325 S. Crawlord Ave
City: Markham State:...IL
Phone Nac 708-333-7300 .. Fix Numben,706 333 7324 ..
Carparatlon
Assaciation
Caak County Business Registration Number. ot APPI)cpbie(Sais Praprietor, Jalnt Venture Pahnemhlp)
Carpamte Ffie Number (if applicable). 71 1861 33
Form af Legal Entity:
( 1 Sale Praprietor [ 1 Psnnership [xi
( I Business Trust [ ( Estate (11 ) Other (descnbe)
[ Trustee af Land Trust
[ I Joint Venture
Ownsmhtp interest D cbusgont
1. List the name[a), address, and percent ownership afeach Peman having s legal or beneficiaiinterest (indudingownership) of more than five percent (555) in the ApplicantlHoider.
Name
URT United Road Tovdng, iac
Address Percentage Interest inApplicant/Heifer
EDS-5 March/2017
CONTRACT NO. 1664-15226
2. If the interest of any Person listed In (I) above is held as an agentor agents, ors nominee orncminses, tist the nameand address of the pdncipsl an whose behalf the interest is held.
Name cf Agent/Nominee Name of Principal Principal's Address
Net.~
ls the Applicant constructively controlled by another person cr Legal Entity? { Q j Yes { ) No
If yes, state the name, address and percentage of beneficial interest of such person, snd ihe relationship under whichsuch control is being or msy be exercised.
Name Address Percentage ofBeneficial Interest
URT United Road Towing. Inc. 18861 90th Ave, ¹E 100vti
Mokena, IL 60448
Relationship
Parent Company
Corporate Ofscers, llembem and Partners Information:
For sll corporations, list Ihe names, addresses, and tenne for all corporate officers, For all limited liability companies, list thenames, addresses Ibr all members. For sll psrtnarships snd joint ventures, list the names, addresses, for each partner or jOintventure.
Name Address Tiss (specify title ofQllice, nr whether manageror partner/joini venture)
Gerald Cnrcoran 18861 80th Ave, ¹ E, Mokens, IL 60448 President
Michael Mahar 18861 90th Ave, ¹ E, Mnkena, IL 60448 Secretary
Term of Ots«m
Perpetual
Perpetual
Declaration (check the spplicabla box):
{2) I state under cath that the Applicant has withheld no disdosure as to ownership interest In the Applicant ncr reservedany information, data or plan ss to Ihs Intended uss or purpose for which Ihe Appycsnt seeks County Board or otherCounty Agency action.
{ j I state under csin that the ««older hss withheld no disdosura m, to ownersnlp interest nor reserved any inrorm stionrequired to be dis«dosed.
Kevin Corcnranoyjdhbb( 'xsg Agpgcl(ngyfa)derRepresentdtive (please pdint'cr fyp'e)
Signature
kcorcoranounitsdrnadtnwlng.cornE-mail address
'Sugp/(gjad'ti:ah de~,rii(xgriis 2(~ dayoui'80+
General Manager
ZI« I)SDate
708-333-7300Phone Number
My commission expires:
Nofary Public'Signature
EDS-9
Notary Seal
I CAT Bjgt March/201
gilled gml
I, Notary Pabgs;-,'SNN««d Igisstb
Nly ccmmlsskjkfgsdfmrdtm 21, 2826
CONTRACT NO. 1664-1 5226
CQQK COUNTY DISCLOSURE OF OWNERSHIP INTEREST STATEMENT
'he Coak CauTriy Codg af 0'idkrfmces (6272610 et sej:.) mqulfss:, cancemfng ownership grterestsTrn the Appgcant. This Disdosurei !Informs(Ba cunent as af the date ibis Statement'Is Id[Fred,Furthe
that any Applicant for any County, Actian must disclose informationaf Ovmersiiip.interest Statement mes( be completed with sll
mrore, this Statement must be kept cunent, by giing an amemledaunty Agency shall take a'dian an; the applkmtlanv The Information contaihed ]hd made avsifable gx'ublic V)eWkrg„County mserves the right to requestrmatlon containeii[)LSSis statame'nt.
'tatement, untg such tinie,ss the Count)[ Board ar C, thN Statement wiN be maintainedSe rs database'sn: ad diviana'I infannatian to verify tlie vs tacky of iiifoj.,lf yau are asked ta list names, but there are no spp!returned snci any sdT[Lsrt moulding this contract will b
icabie names to list, you must state NONE. An incomplete Statement will be', '
4[6[pyed. A failure to fully camply with the ordinance may result in the actiontaken by the Caung)5rggd ar County Agency being vrif
"Acplicanf'eans any Entity or persan making an applicatian ta the County for any County Action.'County Action" means sny action by a Caunty Agency, a Caunty Department, ar the Caunty Baani regarding sn ordinance orardinsnce amendment, a County Board appmvel, or other'County sgbncy approval, with respect ta contracts, leases, ar sale orpurchase of real estate.
Psmon "Enfky'r "Legs/Entity" means a sole proprietorshi, corporation, partnership, assaciabon, business trust, esbile, two armore persans haying a )oint or common interest, trustee of a land lrust, other commercial ar legal entity or any beneficiary arbeneficiaries thereof.
This DNcloaure of Ownership Interest Statement must be submitted by".1,An Applicant farCaunty Action snd2. S)~n, that holds stock or s ~-irigdSNkin the App¹gtt 66J[ Is listed an the Applicant's Statemsni (s 'Holder') must file a
,~ snd complete 61 onlyrufLdsy4amsig[ggtfntemst,D(sggrsson.I Please print sy)i[gin ~jigisriy and legibly. Add additional pages if needed, being rareful ta identify each portion of the form tai which ssdr N)NEorml Pagm~
Thfa statement ls b«ng made by the [ ) Appliaant ar ( x ] stack!Beneficial interest Hakier
This Shrisment is an: [ x ]OriginalStatemsntor [ ]Amended Statement
ldentÃying lnfarma5on:
Name URT Eg R Towing, Inc. - URT United Road Tow[88, Inc,
0!BIA xPert Towing and'RePairr FEIN rtr only r-.82 RSR68.
Sm,«~„18861 90th. Ave SE, Mokena li. 60448
Qty Msrkhem State ~ IL Zip Code %&8Phonshocyg+8%2200 .. ---.4r)MNumber: 7082880&~N .. Email: [email protected]
Cook Caunty Business Registration Number. No~LP[186bip(Sole Proprietor, Joint Venture Partnership)
Carporate File Number (if spplicsbleg 71.1..8.88
Forth of Legal Engtyi
I ] sole Pmprietor [ ] Psrtnemhip [x] corporation [ ) Trustee of Land Trust
[ ) Busirwss Trust [ ] Estate [ ] Association [ ) Joint Venture
[ I Other (describe)
Ownership Interest Declaration:
1. List the name(s), address, snd percent ownership of each Person having a legal ar beneficial interest (includingownership) of mors than five percent (666) in the Applicant/Holder.
Name Address Percentage i«erect inApplicant!Holder
EDS6 March/2017
CONTRACT NO. I 664-15226
If the interest cf any Person listed in (1) above is held as an agent or agents, or a nominee or nominees, list the nameand address of the principal on whose behalf the interest is held.
Name of Agent/Nommee
Not patdlkxfbgr
Name of Principal Principal's Address
Is the Applicant constructively controlled by another person or Legal Entity? [ ] Yes [ ] No
If yes, state the name, address and percentage of beneficial interest of such person, and the relationship under whichsuch control is being or may be exercised.
Name Percentage ofBenegcial Interest
Relatmnship
Corporate Officers„ lgsmbers and Partners Information;
;PER)]l!corpofagprip„bst the names, addtsdses, snd terms for sll corpof'a(a officers. For all limited gpblkty companies, 7/aft]ta[fag[anii'i/ addrgsdsa(br all members. pef a]I psrtnerships and joint ventu'rvby list the names, addresses, for each partner or/]ointImllblgb
Name Address Title (specify title ofOffice, or whether manageror partner/]oint venture)
Term of Office
Oeclaration (check the applicable box):
[ ) I state under oath Ihat the Applicant has withheld no disclosure ss to ownership interest in the Applicant nor reservedsny information, data or plan as to the intended uss or purpose for which the Applicant seeks County Board or otherCounty Agency action.
[x ) I state under oath that the Welder has withheld no disclosure as to ownership interest nor reserved sny informationrequired to be disclosed.
Kevin CorcoranN '," orized Applicant/Holder Representative (please"print'oi'type)
8[goo(bib
kcorcofan/Nunitedroadlow/ng.comE-mail address
Subscribed to and,pwgtf(b jh&'lfgathis 1 day ofJgcaj 2giJ9
f[/A~[II jJ..k»
General Manager
5IIj/a=708-333-7300Phone Number
My commission expires.
EDS-9
Notaiy" p~u Sighat'ure
AEAT EifglI'ffisial SealNotary Public - 6%hj of llllesis
My Commission Expims';Jun 21, 2020
Notary Seal
March/2017
CONTRACT NO. 1664-15226
COOK COUNTY BOARD OF ETHICS69 W. WASHINGTON STREET, SUITE 3040
CHICAGO, ILLINOIS 60602312/603-4304 Office 312/603-9988 Fax
FAMILIAL RELATIONSHIP DISCLOSURE PROVISION
,'Nbnnttint,Dlselnstts'e ReanlremenD
Doing a significant amount of business with the County requires that you disclose to the Board of Ethics the existence of anyfamilial relationships with any County employee or any person holding elective oflice in the State of illinois, the County, or inany municipality within the County. The Ethics Ordinance defines a significant amount of business for the purpose of thisdisclosure requirement as more than $2L000 in aggregate County leases, contracts, purchases or sales in any caiendar year.
If you are unsure 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 fromdoing any business with the County for a period of tiiree years. The required disclosure should be filed with the Board of Ethicsby January I of each calendar year in which you are doing business with the County and again with each bid/proposal/quotationto do business with Cook County. The Board of Ethics may assess a late filing fee of 8 l00 per day ager an initial 30-day graceperiod.
The person that is doing business with the County must disclose his or her familial relationships, lf the person on the Countylease or contract or purchasing from or selling to the County is a business entity, then the business entity must disclose thefamilial relationships of the individuals who are and, during the year prior to doing business with the County, were:
~ its board ofdirectors,a its officers,~ its employees or independent contractors responsible for the general administration of the entity,~ its agents authorized to execute documents on behalfof the 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 familialrelationship disclosure.
Additional Definitions.
"Familial re/aiionihip" means a person who is a spouse, domestic partner or civil union partner ofa County employee or State,County or municipal oQicial, or any person who is related to such an employee or official, whether by blood, marriage oradoption, as a:
.. Parent.. Child
BrotherSisterAuntUncle
: NieceNephew
GrandparentGrandchild
.. Father-in-law. Ivlother-in-law. Son-in-law
. Daughter-in-law
.. Brother-in-law:.. Sister-in-law
'. Stepfather., Stepmother
StepsonI„Stepdaughter
, Stepbrother. Stepsister
Half-brotherHalf-sister
EDS-10 March/20 1 7
CONTRACT NO 1684-15226
COOK COUNTY BOARD OF ETHICSFAMILIAL RELATIONSHIP DISCLOSURE FORM
A. PERSON DOING OR SEEKING TO DO BUSINESS WITH THE COUNTY
Name of Person Doing Business with the County; URT E&R Towina. Inc
Address of Person Doing Business with the County: 16325 S, Crawford Jkve,. Markham, IL 60428
Phone number of Person Doing Business with the County: 708-333-7300
Email address of Person Doing Business with the County; [email protected]
If Person Doing Business with the County is a Business Entity, provide the name, title snd contact information for theindividual completing this disclosure on behalf of the Person Doing Business with the County;Kevin Corcoran, General Manaaer 708-333-7300 708-333-7300.(faxl
DESCRIPTION OF BUSINESS WITH THE.COUNTYAppend additional pages as needed aria far each (Iauniy le'ase, contract, purchase or sale sought andtarobtained dtrrtag the calendar year of this disclosure (ar the proceeding calendar year ifdisclosure is madeon January lj, identify
The lease number, contract number, purchase order number, request for proposal number andlor request forqualification number associated with the business you are doing or seeking to do with the County:
.1 684-15226 ..
The aggregate dollar value of the business you are doing or seeking to do with the County.'$ $ 145,000,00
The name, title and contact information for the County official(s) or employee(s) involved in negotiating thc businessyou are doing or seeking to do with the County;
Edward Lewandowski, Vehicle. Director.. 773v843-6030
The name, title and contact information for the County oftlcial(s) or employee(s) involved in managing the businessyou are doing or seeking to do with the County.'dward
Lewandowski. Vehicle Director 773-843-6031)
C. DISCLOSURE OF FAMILIAL RELATIONSHIPS WITHiCOUNTY EMPLOYEES OR'STATE. COUNTYOR MUNICIPAL ELECTED OFFICIALS,
Check the box that applies aadprovide related information where needed
The Person Doing Business with the County is an individual and there is na familial relationship between thisindividual and any Cook County employee or any person holding elective office in the State of illinois, Cook County,cr any municipality within Cook County.
The Person Doing Business with the County is a business entity and there is nu familial relationship between anymember of this business entity's board ofdirectors, officers, persons responsible for general administration of thebusiness entity, agents authorized to execute documents on behalf of the business entity or employees directlyengaged in contractual work with the County on behalf of the business entity, and any Cook County employee or anyperson holding elective office in the State of Illinois, Cook County, or any municipality within Cook County.
EDS-11 March/2017
CONTRACT NO. 1684-1 5226
COOK COUNTY BOARD OF ETFIICSFAMILIAL RELATIONSHIP DISCLOSURE FORM
The Person Doing Business with the County is an individual and there is s familial relationship between thisindividual and at least one Cook County employee and/or a person or persons holding elective ofgce in the State ofIllinois, Cook County, and/or any municipality within Cook County. The familial relaiionships are as follows:
Name of Individual DoingBusiness with the County
None
Name ofRelated County Title and Position of Related Nature ofFamilialEmployee or State, County or County Employee or State, County Relationship"Municipal Elected Official or Municipal Elected Ogicial
/fmore space is needed, attach an additional sheerfollowing ihe above format.
0 The Person Doing Business with the County is a business entity and there is a familial relationship between at leastone member of this business entity's board of directors, otRtcers, persons responsible for general administration of thebusiness entity, agents authorized to execute documents on behalf of the business entity and/or employees directlyengaged in contractual work with the County on behalf of the business entity, on the one hand, and at least one CookCounty employee and/or a person holding elective otytce in the State of illinois, Cook County, and/or anymunicipality within Cook County, on the other. The familial relationships are as follows:
Nam«of Member of'ourdof Director thr BusinessEntity Doing Business v iththe County
None
Name of Related County Title and Position oi'RelatedEmployee or State, County or County Employee or State, Countylvlunicipsl Elected Otf&cist or Municipal I!leered Otftciat
Nature of FamilialRelationship'
Name ofOtficer for BusinessEntity Doing Business withthe County
None
Nmne of Related County Title and Position of RelatedEmployee or State, County or County Employee or State, CountyMunicipal Elected OAicial or Municipal Elected Oi'ficisl
Nature of I'amiliulRelationship
EDS-12 March/2017
CONTRACT NO. 1684-1 5226
Name ofPerson Responsiblefor the GeneralAdministration of thcBusiness Entity DningBusiness wit!i the County
None
Name ofRelated County Title and Position of RelatedEmployee or State, County or County Employee or State, CountyMunicipal Elected Otlicial or Municipal L'lected Oflicial
Nature ofFamilial
Relationship'ants
of Agent. Autliorimdto Execute Documents forBusiness Entity DoingBusiness with the County
None
Name of Related County Title and Position ofRelated Nature ofFamilialEmployee or State, County or County Employee or State, County RelstiorshipMunicipal Elected Oflicial or Municipal Elected Official
Name ofEmployee ofB usiness Eniity DirectlyFngaged in Doing Businesswith the County
None
Nave of Related County Title md Position of RelatedFmployee or State, County or County Employee or State, CountyMunicipal Elected Official or Municipal Elected Oflicisl
Nature ofFsmilis!Relationship
ifmore space is needed, attach an additional sheetfotlaiving the aboveformac
VERIFICATION: To the best of my knowledge, the information I have provided on this disclosure form is accurate anddomPlnlnv I aoknovfledge that an inaccurate or incomPlete disclosure is Punishable by law, including but not limited to fines and'K/'(,)«SUBMIT COMPLETED FORM TO: Cook County Board of Ethics
69 West Washington Street, Suite 3040, Chicago, illinois 60602Office (312) 603-4304- Fax (312) 603-9988CookCounty.Ethics@cookcounty(Lgov
"Spouse, domestic partner, civil union partner or parent, child, sibling, aunt, uncle, niece, nephew, grandparent or grandchildby blood, marriage (i.e. in laws and step relations) or adoption.
EDS-13 March/2017
CONTRACT NO. 1684-1 5226
SECTION 4
'lXCllgiCGUbgEY g)EFtbkiWfi'FOR'ISSggr-THEFT'ltBYNitkgCE~ Nrgr1 - gtttg'deiibfy Prubg(L bikutitbbw'~~'Satgfbitt(ltggiibagtrag(tCbakgbsggr naad Comply Wah the Ctatbggrunty irtagbfthea,~'std%NitngbtgisybbtattltgtgrISS(gtfa'17$,'ag&seta(SI(~Orant(mygst'fsggtP' 'ggg~'County~'Khilt Ordkniaafsii msyr~CwttbaSNef~~gratgiqafadgwyfr(itggNibt~iigh'igatdgannw
"Coniracf'eans any wrabm document to make Procurements by ar on behalf af Cook County.
person" means any indvidusl, mrparakon, partnership, Joint Venture, bust, association, limited aabaity company, sale proprietarshlp or other legal enaly
, "Pmcuremenf means obtaining supplies, equipment, goads, or ventose of any kind.
'.sfg(mga)bffbosilnt'g(biggagtkbfg'aveftjsbkrggg6%) araidlep~spaaerestin any businesse~ng
'll persansigubsianaal owners are mquired to complete this sllldawl and comply with ths cask caunty vvags Theit onfinance before any contract'ls,i'simnied. Signahss af this farm cansblules a cemgaation the information pnntded below Is correct snd complete, and that the individual(s) a(tining this formkaslhramasrssoal.~.ofstabgofnmation
I. Contrast Infonnagmn:
Co.t mnumben 1~~15226
County Using Agency (request'mg Procurement):Short(f6 Office
II. Psraongubstangal Owner InfonnatlonfURT E&R Towing, Inc
Peman (Corporate Entity Name)
Substantial Owner Complete Norns;
PEINg 82 1280601
Date af Birth:
stm& Addmes (6325 S. CraWfard AVe
Markham
Hams Phone: ( )
States
ken ra or an tgtunited roe dtowi ng .corn
Z.,60428Zipu
III. Compliance with yysge Laws:
within the past five years has the Pemon/substantial owner, in sny (udicisl or admin(atfa(ive proceeding, fkwm donvicted of,entered a gfspb made an admission of guilt or liability, or had as administrative gnding made. for committing a~ or willfulvkifaSbn atshy of the following laws:
iginom Wage Payment and Colection Act, 820 ILCS 155rf et seq., YES a~NO
illinois kfinimum yysge Act, 820 ILCS 1 05/f st seqv YES a~NO
illinois yyorfmr Adjustment snd Retraining Notifmation Act, 820 ILCS 65rf et seq., YES a~NO
Employee Classification Act, 82D ILCS f85/1 et seq., YES a~NO
Pair Labor Standards Act of 1938, 29 U.S.C 201, et seq., YES a~NO
Any compsmbis stale statute or regulation af any stain, which governs the payment of wages YES or NO
if the PersonlSu~ Qwniafansawted "Yes" to any of the questions above, it is ineligible ta enter into a Contract with CookCounty, but can rtfgwst;a.mvrbrdgonv df'wiiiver under Secgon IV.
EDS-14 March/2017
CONTRACT NO. 1664-15226
IV. Request for Waiver or Reduction
If PersonlSubatantial Owner answered "Yes" to sny of the questions above, it may request s reduction or waiver inaccordance with Section 34-1 76(d), provided that the request for reduction of waiver is made on the basis of one or moreof the ioiloviing actions that have taken place'.
There hss been a bona fide change in ownership or Control of the ineligible Person or Substantial OwnerYES or NO
Disciplinary action hss been laken against the individual(s) responsible for the sets g'rving nee io the violationYES or NO
Remedial acffon has been taken to prevent s recurrence of the acts giving rise lc lhe disqualification or defaultYES orNO
Other factors inst the Person or Substantial Owner believe ers relevant.YES or NO
'The pemoriCZubstriri hW'Owrtar mustaubmif dobumantslien to sunnnrtthebasis ofrysrauusst Tora Tedudtfbn or fuahkrr.. Ths Chief;frraoumnls'nt. offkwr re'sriririts'the.rfbhfto nisse uddfffeihtgfndrrfh'eiiintfraduastsdi%l&riaf ddaumenttrkonr
V. AffirmationThe Peta~u'st Owner affinns that ag statements contained in the Aflldavit are true. ~ccumte end complete.
Signature~ Y~ .. Date: -~ ) .IfSName of Person signing (Print): kU. v~ CC~:N Title:
Subscribed snd sworn to before me this:I'ay of PAW ,2g lkx
Notary Public Signature Notary Seat
Hoist The above Information is subject to vedffcatlon prior to ths awsnt of the contrecc
EDS-15 lyl arch/20 1 7
CONTRACT NC. 1684-15226
SECTION 4
:C(M)N.O83ONT(pi'A'ggttgATIIT'E(38'tgfAIETHEET ORE))I)NINCS
'qiii '",;, 'baMay 1, 2otqf etmy Persanrtsar tash'mJtdhshmdhf'tirawrnk seeNhga ghdftfq Jgq(fgigtffggmtgythhfg'gfhqdy vdlh tha'Sdfyfgounty (Litt(gd Thaltisat fcnb in'hgffw 34, Arlictd IY( &iehqf) 118„,yjtfyp(trhphNuby(hf)lhitfhTnsrf'v(tip ftffaf5~Cciih County Wdjje Ttiiilt Ordihtingi may
mqiiesfthst Iha Chiefprncuramant Ogcei giant a reduciian or waiveiin accordnfwsiidthgabtfrm& tyag)$,
"Confmct'eans any vritlen document tc make Prccuraments by cr an behalf of Cook County.
Parson" means any indfviduat, ccrpcrslinn, partnership, Joint Venture, trust, associsucn, limited liability company, sou proprietorship or other legal entlly
"Procur.mant'eans clashing nippllas, equipment, goads, or sou'cas of any kind.
'gutuiffpdtt(chewed'nshuwwlppfssan'er ttefpof% v(haoitni'pf)tightai~ its,sfhflh'@8th) nr'Nfsitfcaqffytsga cf nlsmsi in any business ail/Ill'(tnuthjnga'thhmt)f'p(lh(fagot idfhthtgt(swlk~~)ac~ ps,''t,.bd(imp(n(sf);and pi(tiifjiafs; Idfref(I+here s business sniffy ls an~) or
.Spfh (qh(mptci(ih)P:;~~+dta))(ityh(t'httgfd(d(ybvyy(ft((P'~
, As persons/Substantial owners are required tc cnmplate this affidavit and ccmply wqh the cook county wage Thas ordinanm before sny contract fhawarded. signature of ibis fcan,constlhaes a certification ihe information provided below fs corred and complete, and that the indi&lani(s) signing this form ''as!Siwooanunudknnwhhkmcdnccb)hfolmmfbhi..
I. Contract tnfonnstion:
Contract Number.
County Using Agency (requesting Procurement).
II. PersonfSubstanBal Owner Information:
URT E&R Towing, Inc,Person (Corporate EnNy Name):
Substantial Owner C pletepNms, URT United Road Towing, Irlc.
PEINp %-1233268
Cate of Birth:
street Addresw 15325 S. Crawford Avo
hf(arkhamCity:
Home Phans:
lg. Compgsnce with Wage Laws:
msh Sddmss kcorcoraneunitadroadtowing.corn
State: IL
Within the past five years has the Person/Substantial Owner, in sny )udicisl or administrstwe proceeding, been convicted of,entered a plea, made an admission of guilt or liability, or hsd an sdminislrsdve gnding made for commiiting a repeated or wihfulviolation of any of the following laws:
lanais Wage Payment snd Collection Act, 820 ILCS 1(drf et saq., YES ~NOffsnois Idnimum Nraga Act, 820 ILCS I 05lf et seq., YES o~NO
Ignore Worker Adtusfmsnt and Retraining Nofidcsfion Act 820 ILCS 65rf et seq., YES ~oNO
Employee Cfassfffcahon Jlct, 820 ILCS 18511 atssq., YES o~NO
Fair Labor S(sndards Acf of tg36, 29 U.S.C. 201, etseq., YES ~oNO
Any compambfe stela slainte or regulation of any stats, which governs Ihe payment of wages YES a~NO
If the PersonfSut)htsniftg Ow(lier answered "Yas" to any of the questions above, it is ineligible to enter inta a Contracl with CookCOunty, bu! Can Iavqtnh)t'O rd'duuhcn Or WaiVer under SeCgiOn IV.
EOS-14 March/2017
CONTRACT NO. 1684-(5226
IV. Request for Waiver or Reduction
lf PersonlSubslsntial Owner answered "Yes" to any cf the questions above, it may request s reduchon or waiver inaccordance vtth Section 34-179(d), provided that the request for reducdon ofwaiveris made an the basis of one or moreof the following sdions that have taken place:
Them hss been e bona fide change in ownership or Contml of the ineligible Person or Substantial OwnerYES orNO
Dfbciplinsry action hss been taken against fhs individual(sj responsible for the acts giving rise to the violeiionYES or NO
Remedial ection hss been taken to prevent s recurrencs of the acts giving rise to ihe disqualification or defaultYES or NO
Other factorS lhel ihe Person or Substantial Owner believe afa relevant.YES or NO
They«arab trSufw'fwafsfybwrkrrnull'aujrmE«jj)cinnenlkkm fbstsvfofftha bald( oFiisrstauuafftna~urwsfvurt zlssChfsg«isnrcaasmaat Dibber'ti«witdas ihrrwoht'lutagfut~~sard haffilfsttafdfffo'nsftfrulgiiuuifaffdo«
V. AfgrmadonThe
''lhil',Owner afbrrns that all statements contained in the Atfidawt are true, ~ra(blend complete.
'81(f'tatuhu . - ~~tgd@,; ~
Norns of Person signing (Print)t 4V vy««2«,GTER(Tnt«ty-., Title.P«f S l ~ l
Subscribed and sworn to before me this I day of t'AL«'q. 2()R
, Qu&,6@,Nahiry Public Slgnatum Notary Seel
Note: The shove infannedon ls subject to verlgcstion prior to the swsnf of the Contract
EDS-l5 Msrchf20(7
CONTRACT NO. 1684-15226
SECTION 5
CONTRACT AND EDS EXECUTION PAGEPLEASE EXECUTE TMREE ORIGINAL COPIES
The Applicant hereby certifies and warrants that all of the statements, certifications and representations set forth in this EDS are true,complete and conect; that the Applicant is in full compliance and will continue to be in compliance throughout the term of the Contractor County Privilege issued to the Applicant with all the policies and requirements set forth in this EDS; and that all facts and informationprovided by the Applicant in this EDS are true, complete and correct. The Applicant agrees to inform the Chief Procurement Officerin writing if any of such statements, certifications, representations, facts or information becomes or is found to be untrue, incompleteor incorrect during the term of the Contract or County Privilege.
URT E8R Towing, Inc.
Corporation's Name
708-333-7300
Execution by Corp rattyJ'C~/ ,C IJ T i-~cot'rinted Name and Signature
$ CCi+ c e~p LJ /t, + ej ~o 4 j 6uJ . vr, pAEmttiij EJ
Date
Execution by LI.C
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
SubscJfbed and sworn to before me thist~ day of tVILLLj, 20+)
I
Telephone and Email
My commission expires:
AEAT 2USIOfficial Seal
Notary Public - Stats of illinoisMy Commission Sxpbsa Jun 21, 2020
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-18 March/2017
