Vendor Name: TREATMENT ALTERNATIVES FOR SAFE COMMUNITIES, INC.
(TASC, INC.)
AMENDMENT NO. 1
This Amendment modiflss Contract No. 1553-14823, for Drug Court Assessment Evaluator Servkes by and behveen the County of Cook, gflncis, herein referred to as "County" and Treatment Alternatives For Safe Communities, inc. (TASC, 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 County Board on October 7, 2015, (hereinafler referred to as ihe "Contract"), wherein the Contractor is to provide Drug Court Assessmsnt Evaluator Sunrise (hereinafter referred to as the "Services") from October 1, 2015 through September 30, 2018, with two (2), one year renewal options, in an amount not to sxoeed $516,708.00; and
Whereas, the Contract will expire September 30, 201 8, snd ihe agreed upon Services are still required; end
. Whereas, an Increase in the amount $1 72 236 00 is required for the continuation of Services; and
whereas, the county and contractor desire to renew the contract for twelve (1 2) months beginning on october 1, 201 8 through September 30, 2019; and
Now therefore, in consideraflon of mutual covenants contained herein, it is agreed by and between the parties to amend the Contact ss follows
1. The Contract is renewed through Saptembsr 30, 2018.
2. The Contract ls increased by $172,236.00 and the Total Contract Amount is revised to $688,944.00,
3. Article 5, Compensahon, Section b, Method of Payment, is hereby deleted, in iis snllrety end replaced with the fotlouiing:
"All invoices submritsd by the Contraclor shall be in accordance with the cost provisions contained in ths Contract Documents and shail contain a detailed description of the Deliverables (i.e,, the goads, equipment, supplies, or services) indudlng the qusnflty of the Deliverables, for which payment is requested. Afl invoices for sen/icss shaN induds itemized entries indicsbng the date or time period in which the services were provided, the amount of time spent pwforming the seniices, and a detailed description of ths senricea provided during ihs period cf the invoice. Wl Contrach for services that ars procured as Sole Soume must also contain a provision requiring the Ccnfractor to subinit itemized records indicabng the dates that services were provided, a detailed description of ihe work performed on each such date, and the amount of brims spent performing work on each such date. All invoices shall rsflsct the amounts Invoked by and the amounts paid to the Conlractor as of the date of the invoice. Invrricss for new charges shaN not include "past dus"
amounts, if any, which amounts must be set forth on a separate invoice. Contractor shall not be entitled Io invoice the County fcr any lais fees or other psnalfles.
In accordance with Sscflon 34-177 of the Cook County Procurement Cade, the County shall have a right io set off and sublrsct from any invoice(s) or Contract price, a sum equal to any fines and psnaliies, induding interest, for any tax or fee delinquency end any debt or obligation owed by the Contractor to the County.
The Contractor acknowledges its duty to ensure lhe accuracy of all invoices submitted to ihs County for payment By submilfing ths invoices, Ihe Contractor certifies that all itemized entries set forth in the invoices are uue and correct. The Conk actor acknowkxfges that by submitbng the invoices, it certifies that it hss delivered'the Deiivsrables, i.e., Ihe goods, supplies or equipment set forth in the Contract tc the Using Agency, or that it has properly performed the services set forth
in the Contract The invoice must also reflect ihe dates and amount of flme expended in the provision of senrices under the Contract, The Contractor acknowledges that any inaccurate statsmenfs or negligent or intentional misrspressntshons in ihe invoices shel! result in the County exerciwing all remedies available lo it in law and equity inckxflng, but not limited to,
a delay in payment or non-payment to the Contractor, and reporbng ths matter to the Cook County Olfirxr of the Independent Inspector General,"
Rev 6/I/17
Vendor Name: TREATMENT ALTERNATIVES FOR SAFE COMM(/KITIES, INC.
(TASC, INC.)
4. The IdenltfrcaUon of Bub-Contractors/Suppliers/Sub-Consultants, MBE/WBE Nilization Pbrn and Economic Disdosures Statement under Attachment A are incorporated and made a part of Ibis Contract.
5. All other tenne end 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 written below.
County of Cook, tthnots
Date: I L:Z~ IS'y:
State's Attomdy (if applicable)
Date: IVI'
'I/endor Name: TREATMENT ALTERNATIVES FOR SAFE COMMUNITIES. INC.
tTASC, INC,)
ATTACHMENT A
Rev 6/t/17
Identification of Subcontractor/Supplier/Subconsultant Form
r
The Bidder/Proposer/Respondent ("the'ontractor") will fully complete and execute and submit an Identification of Subcontractor/Supplier/Subcohsultant Form ("ISF") with each Bid, Request far Proposal, end Request far Qualification. The Connector must complete the ISF for sech Subcontractor, Supplier or Subconsultsnt which shall be used on the Contract. In the event that there sre any changes in the utilization of Subcontractors, Suppliers ar Subaonsultants, the Contraclor must file an updated I SF.
Bid/RFP/RFQ No
Contractor.'ASC, Inc.
Date: October 16, 2018
'ubcantractor/Supplier/
Subconsultant to be added ar substitute. Not APPltCablc Authorized Contact far Subcontractor/Supplier/ Subconsultant: Email Address
~Subcontractor):
700 S. Cltnton St. (Subcontractor):
Ci y, St@e and Ch)cagp IL 60607 City, Slate and Zip Zt ts t~t +Subcontractor): TelePhane and F312 573 8771; F312-274-5542 TelePtlane arid Fax Fax (Contractor): (Subcontra~ctar: Estimated.gtsrt and Estimated Start and Completion Dates '10/I/18-9/30/19 Completion Dates
~contractor): tS b ~t
Note: Upon request, s copy of all written subcontrsctar agreements must be provided to the OCPO.
Descrlotion of Services or Suoalles 'otal Price of Subcontract for
Services or Suoolies
Not Applicable
The subcontract documents will incorporate all requirements of the Contraot awarded to the Cantractor as applicable. The subcontract will in no vrsy hinder the Subconlractor/Supplier/Subconsultant from mainlaining its progress on any .other contract on which it is either s Subcontractor/Supplier/Subconsultant or principal contractor. This disciosum is made with the understanding that the Contractor is not under any circumstances relieved of its abilities snd obligations, and is responsible for the organization, performance, and quality of work. This form does not aPprove any proposed changes, revisions or modifications to the contract approved INBE/WBE Utilization Plan. Any changes to the contract's approved MBE/WBE/Utilizatlon Plan must be submitted to ths Oflice of ths Contract Compliance.
TASC, lnc. Co ntractar
Ra)r H. Fcsmlre Name
Date
11s FJ:clark, cDUnty shikahs Room toto e.,chtcesch tltrrosisecsoa e tSL2i Joahsstia
'fOtitkjtaadkallLLNKN
PRESE!ENT
6th District
The OfhCe Of COntraat GOmplianCe ie'n receipt Of the. abOVecreferenoed COntraCt amendment and haa
determined S ttoIO MBEhAJBE participatiOn gOal Wae reoemrnended and deca. nOt require the Qfftoe.cf 'CcritraCt
contpiiance to reviser for MBEAJyBE cohtpiiance-Etiith the.Minority. snd tftiomen-YJttlned Business Enterprises
fMBEiWBE} Ordinance,
GREGE GOSUN
14tli District
CONTRACT ip. 1553-14823
AND EXECUTION DOCUMENT INDEX
Certifk:ations
f arid Familial Relationship Disclosure Form
Cook County Affidavit for Wage Theft Ordinance
EDS 1-2
EDS 3-12
EDS 13-14
CONTRACT d.'553-14823
ECONOMIC DISCLOSURE STATEMENT AND EXECUTiON DOCUMENT
This Economic Disclosure Statement and Execution Document ("EDB") Is tb be completed and executed by every Bidder on a County contract, every Proposei responding to a Request for Proposals, snd every Respondent responding tc a Request for Qualifications, and others as required by the Chief Procurement Officer. The execution of the EDS shall serve ss the execution of a contract awarded by \he County. The Chief Procurement Officer reserves the right to request that the Bidder or Proposer, or Respondent provide sn updated EDS on an annual basis.
Definitions. Terms used in this EDS and not otherwise defined herein shall have the meanings given to such terms In the Instructions to Bidders, General Conditions, Request for Proposals, Request for Qualifications, as applicable.
Afiflists means a person that directly cr indirectly through one or more intermediaries, Controls is Controlled by, or is under common Control with the Person specified.
Applicant means a person whc executes this EDS,
Bidder means any person who submits s Bid,
Cods,means the Cods of Ordinances, Cook County, illinois available cn municode,corn.
Contract shall include any written document to make Procurements by or cn behalf cf Cook County.
Confracfcr or Contrsciing Party means a person that enters into s Contract with ths County.,
Control means the unfetl'aisd authority to directly or indirectly manage governanc, 'dministrabon,work, and all other dspscts of a business.
EDS means this complete Economic Disclosure Statement and Execution Dopument, inciuding all sections listed in the Index and sny attachments,
Joint Venture means an association of two or mors Persons proposing to perform s for- profit business enterprise, Joint Ventures must have an agreement In writing specifying the terms snd conditions of the relationship between the partners and their relationship and 'respective responsibility for the Contract
Lobby or lobbying means tc, fcr compensation, attempt to influence a County cfficisi or County employee with respect to any County matter.
Lobbyist means sny person who lobbies.
Person or Persons means any individual, corp'oration, partnership,,Joint Venture, trust, association, Limited Liability Company, sets proprietorship or other legal entity.
Prohibited'cts means any of the actions or. occurrences which form the basis for disqualification under the Code, or under the Certifications hereinafter set forth.
Proposal means a response to an RFP,
Proposer means a person submitting a Proposal.
Response means response to an RFQ.
Respondent means a person responding to an RFQ
RFP means e Request for Proposals issued pursuant to this Procurement Code
RFQ means a Request for Qualifications issued to obtain the qualifications of interested parties
CONTRACT ff: 1553-14823
INSTRUCTIONS FOR COIIIIPLETION OF ECONONIIC DISCLOSURE STATEMENT AND EXECUTION DOCUMENT
Section 1: lnstrucffons. Section 1 sets forth the Instructions for completing and executing this EDS.
Section 2: Certificatlons, Section 2 sets forth ceitiflcations that are required for contracting parties under the Cade and other applicable laws. Execution of this EDS constitutes a warranty that all the statements and certlfications contained, and all the facts stated, in the Certifications are true, correct and complete as of ths date of execution.
Section 3: Economic'and Other Disclosures Statement. Section 3 is the County's required Economic and Other Disclosures Statement'orm, Execution of this EDS constitutes a warranty that all fhe information provided in the EDS is true, correct end complete as of the date of execution, and binds ths 'Applicant to the warranties, representations, agreemsnts and acknowledgements contained therein.
Required Updates. The Applicant is required to keep all information provided in this EDS current and accurate. In the event cf any change in the information provided, including but not limited to any change which would render inaccurate or incomplete any cs)tificstion or statement made in this EDS, the Applicant shall supplement this EDS up to the time the County takes action, by filing an amended EDS or such other documentation as is required.
Additional Information. The County's Governmental Ethics and'ampaign Financing Ordinances impose certain duties and obligations on persons cr entities seeking County contracts, work, business, or transactions, and the Applicant is expected to comply fully with these ordinances. For further information please contact the Director of Ethics st (312) 603-4304 (69 W. Washington St. Suite 3040, Chicago, IL
60602) or visit the vfeb-site at cookcountyil.gov/ethics-board-of.
Authodzed Signers of Contract and EDS Execution Page. if the Applicant is a corporation, the President and Secretary must execute the EDS. In the event thai this EDS is executed by someone other than the President, attach hereto e certified copy of that section cf ihe Corporate By-Laws cr other authorization by the Corporation, satisfactory to ths County that permits the person lo execute EDS for said corporation, lf the corporation is not registered in ths Stets of Illinois, a copy of the Certificate of Good Standing from the stats of incorporation must be submitted with this signature Page,
If the Applicant is a partnership or joint venture, all partners or Joint vsnturers must execute the EDS, unless ane partner or joint venture has been authorized tc sign for the partnership or joint venture, in which case, the partnership agreement, resolution or evidence of such authority satisfactory to the Offlce of the Chief Procursmsnt Oiffcsr must be submitted with this Signature Page,
If the Applicant js a member.managed LLC all rnernbers must execute the EDS, unless otherwiss provided in the operating egrsemsnt, resolution or other corporate documents. If the Applicant is a manager-managed LLC, the manager(s) must execute the EDS. Th'e Applicant must attach either a certified copy of the operating agreement, resolution or other authorization, satisfactory to the County, demonstrating such person hss the authority to execute the EDS on behalf of the LLC. If the LLC is not registered in the State of Illinois, a copy of a.current Certificate of Good Standing from the state of incorporation must be submitted with this Signature Page.
If the Applicant is a Sole Proprietorship, ths sc(e proprietor must execute the EDS.
A "Partnership" "Joint Venture" or "Sole Proprietorship" operating under an Assumed Name mist be registered with the Illinois county in which it is located, as provided in 505 ILCS 405 (2012), and documentation evidencing registration must be submitted edith the EDS.
Effective October 1, 2016 ag foreign corporations and LLCs must be registered with the illinois Secretary of State's Offic unless s statutory exemption applies to the applicant. Applicants who are exempt from registering must provide a written statement explaining why they are exempt from registering as s foreign entity with the illinois Secretary of State's Office.
Eos-II
CONTRACT FR 1563-14823 '
THE FOLLOWING CERTIFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE, THE APPUCANT IS CAUTIONED TO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE. SIGNING THE SIGNATURE PAGE SHALL CONSTITIJTE A WARRANTY BY THE APPi ICANT THAT ALL THE STATEMENTS, CERTIFICATIONS AND INFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRUE, COMPLETE AND CORRECT AS OF THE DATE THE SIGNATURE PAGE IS SIGNED. THE APPLICANT IS NOTIFIED THAT IF THE COUNTY LEARNS THAT ANY OF THE FOLLOWING CERTIFICATIONS WERE FALSELY MADE, THAT ANY CONTRACT ENTERED INTO WiTH THE APPI.ICANT SHAI.L BE SUBJECT TO TERMINATION.
A. PERSONS ANO ENTITIES SUBJECT TO DISQUALIFICATION
No person ar business entliy shall be awarded a contract or sub-contract, for a period of five {5} years fram the date of canvlctian ar entry of a'lea or admission of guilt, civil or criminal, if that person ar business entity.
1) Has been convicted of an act carnmitted, within the State of illinciis, af bribery or attempting to bribe an officer ar employee of a unit of state, federal ar local government or schoal district In the State af illinois in that office's or smplayee's otgclal capacity;
2) Hss been convicted by federal, state or local government of an sct of bid-ngglng oi attempting to rig bids as defined In gre Sherman Anti Trust Act and Clayton Act. Act, 16 USC. Section 1 el sagJ .Has been convicted of bid-rigging ar attempting to rig bids under the laws of federal, state or local government;
Has been convicted af en sct committed, within the Stats, of price-fixing ar attempting ta flx prices as defined by the Sherman AntiTrust Act and'ths Clayton Act. 16 USC, Section 1, et segJ'ss
been convicted of price-tixlng ar attempting to fix prices under the laws the State; 'ss been convicted of defrauding or attempting to defraud sny unit ot state ar locai government or school disirict within the Stats of lfllnais;
5)
6)
7) Has made an admission of guflt of such conduct as set forth in subsections (1) through {5) above which admission is a matter of record, whether or not such persan or business entity was sub)sct to prosecution for Ihe offense or offenses admitted to; or
8) Has entered a plea of nolo contendere to charge of bribery, prfce-fixing, bid.rigging, or fraud, as set forth In sub- psregrsphs (1) through (6) above.
In ths csee of bribery or attempting to bribe, s business entity msy not be awarded a contract 3 sq official, agent or employee of sUch business entily committed the Prohibited Act on behalf of the business entity and pursuant to Ihe direction ar authorization af an offlcer, dlrscfor or other respansible atflclst of ths business entity, snd such Prohibiled Act occurred within three years prior to ths award of the contract. In addition, a business entity shall be disquagfled if sn owner, partner or shareha(der cantralling, directly or indirectly, 20'yi or mors of the buNiness entity, or sn afficer of the business entity has performed any Prohibited Act within five years prior ta the award cf the Contract,
THE APPLICANT HEREBY CERTIFIES THAT: The Applicant hes read the pravlslons of Section A, Persons and Entlliss Subject ta Disqualification, that the Applicant has not committed any Prohibited Act sst farih in Section A, snd that award of the Contract ta the Applicant would not vlalste the provisions of such Section or of the Cods.
B. BIO-RIGGING OR BID ROTATING
THE APPLICANT HERESY CERTIFIES THAT: In scconiencs with T20 ILGS 5I33 E-11, nsitirer the Appflcsnt nor sny AIIiiisted Engiy is barred Iiam award of this Conirscf as s result of e conviction for the viaisiian of Sfsfs laws pmhiblting bid- rigging or bid mfaifng,
C. DRUG FREE WORKPLACE ACT
THE APPUCANT HEREBY CERTIFIES THAT. Ths Applicant wifl provide a drug free workplace, as required by (30 ILCS 580/3).
Eosnl
D. DELINQUENCY IN PAYMENT OF TAXES
THE APPLICAhtT HERES Y CERT IPIES.THAT:?hs Applicant Is not sn owner ar s party responsible for the payment of sny tex or fee administered tbr Cook County, such as bsr'sward of s contract ar subcantrect pursuant fo ths Code, Chapter 34, Section 34-1?L
E, HUMIAN RIGHTS ORDINANCE
No person who br a pony to a contract wilt Cook County ("County") shall engage in unlawful discrimination or sexual harassment against any individual in the terms or conditions of employment, credit, pubic accornrnodstians, housing, or pnwision of County facilltiss, services or programs (Code Chapter 42, Section 42-30 st seq.).
F, ILLINOIS HUfifiAN RIGHTS ACT
THE APPLICANT HERESY CERTIFIES THAT: It is in compliance with ths Illinois Human Rights Act (775 ILCS &2-105), snd agmes to abide by ths mquirsments of the Act as part of ifs contractual obligations.
G. tNSFECTOR GENERAL (COOK. COUNTY CODE, CHAPTER 34, SECTION 34-4?4 snd Secdon 34-260)
The Applicant hss nct willfully failed to cooperate in an Irwsstigatlon by ths Cook Caunty'Independent Inspector General or to report ta the Independent Inspector General any and atl information concerning conduct which they know to involve conuptlon, or other cdrninai activity, by another county employee or official, which cancsms his ar her office of employment or County related transaction.
The Applicant hse refxxted directly and without any undue delay any suspected ar known fraudulent acfivky In the County's Pracurement process to the Office of the Cook County Inspsator Genera(.
H. 'AMPAIGN CONTRIBUTIONS (COOK COUNTY CODE, CHAPTER 2, SECTION 2-635)
'HE APPLICANT CERTiFIES THAT: It has read and shel comply with the Caok Caunty's Ordinance concerning campaign cankibuiions, which is ccdltied st Chapter 2, Divislan 2, Subdivision 0, Section 635, snd can be read In Its entirety at wlfiu itiunnloghgarg,
I. GIFT BAN, (COOK COUNTY CODE, CHAPTER 2, SECTION 2474]
THE APPLICANT CERTIFIES THAT: It hss read snd shall comply with the Cook Caunty's Ordindnce concerning receiving end saliciling gilts and favors, which Is codified at Chapter 2, DiviNon 2, Subdivision It, Section 574, arid csn be read in its entirety at www.municade.corn.
LIVING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34 180;
Unless expreesbi waived by the Cook County Board cf Cammlssianers, the Code requires that a living wage must be paid ta individuals employed by a Contractor which has s Caunty Contract and by sll subcontractors of such Contractar under e County Contract, throughout the duration of such County Contract. The amount of such lving wage Is annually by the Chief Finarelal ONcsr ofthe Caunty,. and shel be posted on the Chisl Procurement Officer's website,
The term "Contract" as used in Section 4, I, of this EDS, specifically excludes contracts with the fcfiawtng:
1) Not-For Profit Organizations (defined as a corporation having tax exempt status under Section 501(C){3) of the United State Internal Revenue Code and recognized under the llinais State not-far -prafii law);
2) Community Development Block Grants;
3) Coak County.Works Department;
5) Department ofCorrection inmates.
1. DISCLOSURE OF LOBBYIST CONTACTS
Lists«persons that have made lobbying contacts on your behalf with respect to this contract:
Name N(A
1. LOCAL BUSINESS PREFERENCE STATEMENT (CODE, CHAPTER 34, SECTION 34-23«)
Local business means a Person, including a foreign corporation authorized to transact business In 'illinois, having a bona fide sstabl(shment located within the County at which it ls transacting business on ths date when a Bid is submitted to the County, and whirh employs the ma]ority of its regular, full-time work force within the County. A Joint'Venture shall cons«tutu. a Locai Business If one or mare Persons that qualify as a "Local Business" hold Interests totaling over 60 percent in the Joint Venture, evan if ths Joint Venture does not, at the time of the Bid submittal, have such a bona fide establishment within the County.')
Is App«cant a "Local Business" as defined above'?
b) If yes, list business addresses within Cock Couniy,
60607
2& 20 W. I(003«ye(t Rr(..'hicsuo. IL 6060&
c} Does Applicant employ the ina)ority of its regul«r full-time workforce wi«iin Cook County'?
Yes+] No:
3. THE CHILD SUPPORT ENFORCEMENT ORDINANCE (CODE, CHAPTER 34, SECTION 34-172)
Every Applicant for a County Privilege shall be In full compliance with any child support order before such Applicant is snfitled to receive or renew s.Coun(y Privilege. When delinqu'ent child support exists, ths County shall not issue or renew sny County Prtvllsge, and may rev'oke any County Pdvttege.
All Applicants are required to review the Cook County ANIdsvlt of Child Support Obligagons attached to this EDS (EDS-5) and bompleti the A%davit, based on the instructions in the Affidavit,
EDSS
4. REAL ESTATE OWNERSHIP DISCLOSURES.
The Applicant roust Indicate by checking the appropdrate proyision below and providing all required information that eithen
a) The following is a complete list of all real estate owned by the Applicant in Cook County:
PERMANENT INDEX NUMBER(S):17-16-305-019-0000, 17-16-305'-020-0000, 17-16-305-07,1-0000,
NUMBERS)
b) The Applicant owns no real estate in Cook County.
5. EXCEPTIONS TO CERTIFICATIDNS OR DISCLOSURES
If the Applicant is unable to certify to any ot the Cerlificakons or any other statements contained in this EDS and not explained elsewhere In
this EQS, the Applicant must explain belovr.
NlA
lf the letters, "NA", the word "None" or "No Response" Sppeers above, or if the space is left blank, il will be condusiveiy presumed that the ApplicantcsrtNed to sk Cerlitlcatlons and other statements contained in this EDS.
EDSX
COOK COUNTY DISCLOSURE OF OWNERSHIP iNTEREST STATEMEMT
The Cook County Code of Ordinances (22-618 st seq.) requires that any Applicant for any County Action must d(sciose information concerning ownership interests in ths Applicant. This D(sctosure.of Ownership lhtereet Statement must be completed with all information current as of the date this Statement is signed. Furthermore, this Statement must be kept current, by giing en amended Statement, until such time as ths County Board or County Agenoy shall take ection on the application. The information contained in this Statement will be maintained in a database and made available for public'viewing. County reserves the right to request additionai information Io verify verse(ty of Information contalnted In this statement.
If you are asked to list names, but there are no applicable names to list, you must state NONE. An incomplete Statement will be returned and any sc((on regarding ihis contract will be delayed. A failure to fully comp(y with the ordinance may result in the action taken by the County Board or County Agency being voided.
AAppllcsnil means sny Entify or person making an application to the County tor any County Action.
"County Ac(ion" means any ection by s County Agency, a County Departmen(, or the County Board regarding an ordinance or ordinance amendment,.a County Board approval, or other County agency approval, with respect to contracts, leases, or sale or purchase of real estate, "Person" "Enfll'yd or "Legal Eng(y" means a sole proprietmship, corpora(ion, partnership, association, business trust, estate, two or
more persons having 6 (oint or common Interest, trustee of a land trust, other commercial or (egal entity or any beneficiary or beneildaries thereof.
Idt'dh I'III ttlld
, This Disdosure of Ownership interest Statement must be 'submitted by: 1. An Applicant for County Action snd
2, A Person that ho(ds stock or a benslicta( interest in the Applicant ((Lnd is listed cn the App((cant'6 Statemenl (a "Ho(dad) must file a Statement arrd complete f(1 only under Ownership Interest Denim'ation.
Please print or type responses clearly and legibly. Add additional pages if needed, being cerefu! to identify each po(t(on of ihs form to hid d ddll Ip p I
Phl dt I tl ~ h d d hhth Igthhhll
This Statement ls an. [QI Original Statement or [ ] Amended Statement
Identifying information:
City,'h(carpe Phone Noc 312-787-0208
Corporate. File Number gf app((csb(e);
Form of Legal Engty:
Sole Froprletor Q Partnership
Business Trust Q Estate .
501 '(c) (3) Association g Joint Venture
Other (describe)
Ownership interest Dsclaradon:
!
Address Percentage Interest in Apprrcant/Holder
2. If ths interest of any Person listed in (1) above is held as an agent or agents, or a nominee or nominees, list the name and address of ths principal on whose behalf the interest is held.
Name cf Agent/Nominee Name of Principal Principsfs Address N/A
is the Applicant constructively controlled by another person or Legal Entity'/ ( j Yes ( X ) No
If yes, state the name, address and percentage of beneilclai interest of such person, and ths relationship under which such control is being or may bs exercised.
Name Address Percentage of Beneficial Interest
Relationship
Corporate Officers, Isiembers snd Partners Information;
For sll corporations, fist the names, addresses, and terms fcr all corporate officers. For all limited liability companies, list'the names, addresses for ail members. For sll partnerships and Joint ventures, list the names, addresses, fcr each partner or joint venture.
Term of OtflceAddress Title (specify title of Oflice, or whether manager or partnerljoint venture)
See attached. Corporation is a Not-For-Profit Corporation and therefore no Corporate 0%cere or
~~rH Mc rnh~|.c h~ve sn~ ownr rshin interest in the Cornbration.
Declaration (ohsctt the applicable box):
gJ ' stats under oath thai the Applicant has withheld no disclosure as tc ownership interest in ths Applicant nor reserved
any infcrmaaon, dais or pion as lo Ihe intended use or purpose for which the Applicant seeks county Board or other county Agency action.
I state under oath that lhs Holder hss withheld no disclosure ss to ownership interest nor reserved any information required to be disclosed.
Eos-f
Roy H, Fesmire
(r'ill ~ I Z BP Date
Rfesmirettasc.org 312-573-8271 E-mail address Phone Number
Subscdbe¹ to and sworn before me this dsy of~PC, 20~ My commission expires:
"Notary Pubtiorgignsture Notaty Seal
8Oard Of DireCtOrS ((sterna(UseOn(y)
~ Ms. Michelle M. Montgomery Chair Attorney at Law James D. Montgomery (it Associates, Ltd. One North LaSalle St., Suite 2450 Chicago, IL 60602 Phone: 312-726-4053
l Cell: 773-580-7344 Fax: 312-977-0209 Email: muuuijdut(aw.corn
Mr. John J. ZieHnski, CFA, CFP Vice Chair and Secretary Managing Director Opthnum Investment Advisors, LLC 33 N. LaSalle St., Ste., 3700 Chicago, IL 60602 Phone: 312-456-3314 Fax: 312-782-9797 Cell: 815-277-7949 Eutaik jzielinskilopumuut(nvestmeut.corn
Mr. Andreason Brown Treasurer CluefFinancial Officer Spencer Foundation 625 N. Michigan Ave., Ste. 1600 Clt(cage, IL 60611 Phone: 312-274-6522 Cell: 312-773-316-6130 Fax: 312-337-0282 Email: abrownispencer.org
Ms. Creasie F. Hairston, PhD Dean, Professor ofSocial Work Jane Addauis College ofSocial Work University ol'Illinois at Chicago 1040 W. Harrison, Room 4010 Chicago, IL 60607 Phone: 312-996-3219 Fax: 312-996-1802 Email: c(h@uic,edu
Mr. Jason Hutton Vice President, Huulan Resources Fanuly Health Network 322 S. Green St, 4th Floor Chicago, IL 60607 Phone: 312-880-1685 Fax; 312-626-1499 Entail: jhutton (hnclucago.corn
Ms. DeAnna I, Jones Senior Analyst NEPC,LLC 10 S. Wacker Dr, Chicago, IL 60606 Phone: 312-585-9687 Cell: 312-931-7052 Fax: 617-374-1313 Fmaih djonesthenepc.corn
TASC, inc, is an hidependent, not-fot-pmfit agency that
provides dhncal case management and other services to mni, women
and adolescents with a wriety of social and health-sehted needs.
Mr. Glenn Blackmon 1239 W. Early Ave. Clucago,IL 60660 Phone:847-421-1027 Email: gblackmon1@gntaiLcom
Administrative c3fficea 700 S, Chnton St.
Chicago, IL 60607 teh (312) 287-0208 fax: (31 2) 787-9663
www.taac.org O Msy2018TASC, Inc.
CONTRACT ¹: 1553-1 4823
COOK COUNTY BOARD OF ETHICS 69 W. WASHINGTON STREET, SUITE 3040
CHICAGO, ILL1NOIS 60602 312/603-4304 Office 312/603-9988 Fax
FAMILIAL RELATIONSHIP DISCLOSURE PROVISION
Nenotism Disclosure Reauh ement
Doing a sigcigcmt amount ofbusiness with'the County requires that you disclose to the Board of Ethics the existence of any gmuHal relationships with acy C'ounty employee or any person holding elective oi6ce in the Smtc of Illinois, the County, or in any municipality within the County. The Ethics Ordinance degnes s signigcsnt amount of business for the purpose of this disclosure requireinent as more than 825,000 in aggregate County leases, contraots, purchases or sales in any calendar year.
it you sre unsure of whetbm the business you do with the County or a County agency will cross this threshold, err on the sids of caution'y completing the anached familial disclosure form because, among other potential penalties, any person ibund guilty of failing to make s required disclosure or knowingly filing a false, misleading, or incomplete disclosure will be prohibited 6 om doing any business with the County for a period of three years. The required disclosure should be Gled with the Bowd ofEthics by January 1 of each calcndai'ear In which you are doing business with the County and again with each bid/propcsaVquotatfon to do business with Cook County. The Board of Ethics may assess a late Bitng fee of $100 per day alter an initial 30-day grace perioA
The person that h doing business with the County must disclose his or her gtmilial relationships. If the person on the County lease or contract or purchasing 6'om or selling to the County is a b'ushmss entity, then the 'business entity roust disclose the familial mlatioashlps of the Individuals who are and, during the year prior to doing business with the County, were;
~ its board ofdirectors, ~ its cfgcers, ~ its employees or independent contraotors responsible for the general administration cf the entity, ~ its agents authorized to exeowe documents on behalfofthe entity, and ~ its employees v/ho directly engage or engaged in doing work with the County.on behalf ofthe entity,
Do not hesitate to contact the Board of Ethics at (312) 603.4304 for assistance in determining the scope of any required Sunilial relationship disclosure.
Additional De6aiticnsi
aFarngial re/arionshlp" means a person who is a spouse, domestic partner or civil union partner of a County employee or State, County or municipal of6cial, or any person who is related to such an employee or ofgcial, whether by blood; marriage or adoption, as
CIParent CIChild CIErother CI Sister DAunt Cj Uncle CINiece CINephew
CIGrandparcnt CI Grandchild CIFatherin-law CI Mother-in-law CISon in-law Cj Danghterin-law Ci Brotherin-law Cl Sister-in-law
CI Stepfather Ci Stepmother CI Stepson CI Stepdaughter CI Stepbrother CI Stepsister Ci Halpbrother CI Halfsister
EDs-s
1
CONTRACT fk 'l658-14828', PERSQN DOING OR SEEKING TO DO BUSINESS WITH THE COUNTY
Name cfPemon Doing Business with the County: TASC, Inc
AddressofpersonDomgBuslnessudthdm County, 700 S. Clinton St,
Phone number ofPerson Doing Business with the County: 312-787-0208
Rmaii address ofPerson Doing Business with the County: Rfesmire@tasc.orn
If Person Doing Bmmess with the County is a Business Entity, provide the name, title aad contact information for the individual completing this disolosure on behalfof ihh PersonDoingBusmess with the County:
Roy H. Fesmirc, Vice President.and CFO, 312-573-8271, Rfcsmircimrasc.erg
DESCMPTION OF BUSINESS WITS TBE COUNTY Append additionalpager «s needed andfor ea'ch County /sass, contract, purchase or sale scughr and ar obtained during the calendaryear afrhiz'/salasure (or thepracesdrng calendar year lfd/sc/arure /s made an January I), tdsntt(yr
The lease number, contract number, purchase order number, request for proposal number and/cr'represt for qualification number associated with the business you are doing or seeking to do with the County,
Contract No. 1553-14823
The aggregate dollar value oftbc business you am dhmg or seeking to do with the County: 8
The name, title and conmct mformation for the County of6ciai(s) or employee(s) involved in negotiatlug the business you ai'e
dctug o'r seeldng to do with the County,
Colleen Swenson, Problem Solvin Court Coordinator, Adult Probation Department
The name, title and contaot lnfoimatldn for the County of6cial(s) or employee(s) involved in managing the busiuess you are doing or see!dug ui do with the County;
Colleen Swenson, problem Solving Co'urt Coordinator, Adult Probation Department
C. DISCLOSURE OF FAMILIAL RELATIONSHIPS WITH COUNTY EMPLOYERS OR STATIr- COUNTY OR MUNICIPAL ELECTED OFFICIALS
Check ihs box that applies andprov/ds related lq(hrmarrcn where needed
The Person Doing Business v/ith the County is an individual and there h no familial relationship between this individual and any Cook County employee or st0 person holding elective oflice in the State ofUhnois, CookCounty, or sny municipahty within Cook County.
The Person Doing Business with the County is a business entity snd there is no familial relationship between any member of this business entltyis board ofdirectors, officers, persons responsible for general administration,ofthe business'entity, agents authorized to execute documents an behalfof the business entity or employees directly engaged in ccntmctual work with the County on behalfofthe bushmss entity, and sny Cook County eniplcyee or any person holdmg elective ofgce in the State of Illinois, Cook County, or any municipality wlthln Cook County,
Eos-1 0
COOK COUNTY BOARD OF ETHICS FAMILIAL RELATIONSHIP DISCLOSURE FORM
The Pmson Doing Bushtess with the County is an individual an'd there is a familial relationship between this iudivldusl and at least one Cook County employed and/or a person or persons holding elective oflice in the State ofIllinois, Cook Couniy, and/or sny municipality within Cook County. The familial relationships are ss follows:
Name of individual Doing Bus'mess with thc County
Name ofRelated County'itle and Position of Related Nsntrc ofFmnigal Employee or State, County or County Employee or State, County Rehticnship Municipal Elected 016cisl or Muoicipsl Elected Offlcial
/fmore speed is needed, attach an addittonalsheetfollowing the aboveformat
The Person Doing Bmmess wilt the County is a business entity and there is a familial relationship between. at least one member ofthisbusiness entity's board ofdh eotors, ofScers, persons responsible for general administration of the business entity, agents authorized to excoute documents on behalf of the business entity snd/or employees dhectty engaged in contractual work with the'County on behalfofthe business entity, on the one hand, and at least ooe Cook County employee and/or s person holding elective of5ca in the State of Ilhnois, Cook County, and/or any municlpalky within Cook County, on the other. The familial relationships are as follows:
Name of Member of Board of D/rector for Business Entity Doing Business with thc County
Name ofRelated County 'itle snd Position ofRehted Employee or Stme, County or County Employee or State, County Municipal Elected Offlcisl or Municipal B'lected Offlcisl
Nanna sfFamilial Relationship
Name of Offlcer for Business Name of Related County Title and Position ofRelated Entity Doing Business with Employee or Stets, County or County Employee or State, County the County Municipal Elected OFicial or Municipal Blasted Official
N/A
CONTRACT g: 1553-14523
Name ofPerson Responsible 'ame ofRelated County for theQeneral Employee or State, County or Administration of the Municipal Elected Ofgciai Business Entity Doing Business with the County
Title and Position ofRelated Nature ofFamilial County Employee or State, County Relationship ar ivlunlclpal Elected Official
Name ofAgcat Authorised Name ofRelated County Title and position of Related to Execute Documents for Employee ar State, Cauaty ar County Employee ar State, County Business Bntity Doing Municipal Elected Official or Muulcipal BiectedOfgcial Business with the County
Nature ofFamilial Relationship
Name ofBmployee af Business Entity Directly Engaged in Being Business with the County
Name ofRelated County Title snd Position afRelated Nature of FandUal Employee or State, County or County Employee m State, County Relationship'. hfunicipal Elected Official 'rMunicipal Elected Ofdcial
amore space D needed, clinch an additional sheetfoffowfng the aboveformol.
VERIli'ICATIONt To the best of my knowledge, the information I have provided on this disclosure form is accurate nnd complete. I acknowledge that an hIffccurate or incomplete disclosure is punishable by law, including but not limited ta Snes and debanncnt.
/X (~ ' ) . io/'4Ji:d SignaturepofReoipicgtg Date
SVBSSIT COMPLETED FORM TOi Cook County Bomd ofEthics 69 West Washington Stmet, Suite 3040, Chicago, Illinois 60602 Office (3 12) 603-4304- Fax (312) 603-9988 CookCounty.Bthios@caokcountyiLgav
* Spouse, domestic partner, civil union partner or parent, chBd, sibling, aunt, uncle, niece, nephew, grandparent or grandchild by blood, marriage (I a in laws and step relations) or adoption.
EDS.12
COOK COUNTY AFFIDAVIT FOR WAGE THEFT ORDINANCE
Effective Mey 1, 2315, every person, inc/ud/na sobs/an//s/ owners, seeking a contred with cook county must camply with ths cook county Wage TheR Ordinance eet forth In Chapter 34, Artlde IV, Section 179. Any Person/Substantial Owner, who falls (o comply with Cook Cauniy Wage Then Ordinance, msy request that tha Chief Pracununsnt Officer grant e reduction or waiver in accordance with Sedion 34579(d). "Con/res/" means any written document to make Pmcurements by or on behalf of Cook County. "Person" means eny indiv/dual, corporation, partnership, Joint Venture, trust, association, limited liability company, sole prapristorship or other legal entity. "Procuremsnl" means obtaining supplies, equipment, gauds, or services of any kind,
"substsnliel Owner'eans any person or persons who own or hold a twenty-ffve percent (25%} or more percentage af interest In any.business ent/ty seeking a County Privilege, Indudlng those shareholders, general or limited partners, beneficiaries and principals; except where e business entity ls an Individual or sole proprietorship, Substantial Owner mesne that Individual or sole proprietor.
All Persons/substantial owners are required to complete ibis affidavit snd camply with the cook counbr wage Theft ordlnsnm before eny contract ls awarded. Signature af this form constitutes a csrtiTicetion the inforrnatian provided below is correct snd complete, end that ths Individual(s) signing th/s form has/have personal knew/edge af such information. County reserves the right to request additional Infarrnatian ta verify veracity af informntlan conhilned in this Afgdsvth
L Contract Information: 1553-14823
II. Person/Substantial Owner Information:
Substantial Owner Complete Name:
City; Chicago
Horns Phone; ( )
State: Ii Ei 60607
VVithin the past five years has ths Person/Substantial Owner, in nny iud/cial or adm/nistrative praceeding, been convicted of, entered a plea, made an admission of guilt or liability, or had an administrative finding made fcr committing a repeated cr willful violation of any of ths following laws:
Na ////nois Wage Paymentsnd Co//action Acf, 820/LCS 15875 stseq.,
No ////na/s Minimum Wage Acf, 820/LCS 508/5 etseq
No ///ino/a Wor/rsrAdjustment and Retaining NotNcagon Act, 820 I LOS 88/5 sf seq
No Emp/ayee C/uss//ica//cn Acf, 820 ILCS 585'5 etseq.,
No Fair Labor Standards Aa/ of 1938, 28 U.S.C. 201, sf ssq.,
No Any compareb/s state s/etufe or rsgufa//on afsny sts/s, which governs Ihs payment of wages
If the P'erson/Substantial Owner answered xYesx to any of ths questions above, it is ineligible ta enter Into a Contract with Cook County, but cen request a reduction or waiver under Section IV.
EDS-1 3
CONTRACTtk )553-14823
IV. RequestforWalverorReduction
If PersoniSubstential Owner answered "Yes" to any of Ihe questions above, II may request a reduction or,waiver In accordance with Section 34-179(d), provided that the request for reduction of waiver Is made on the basis of one or more of the following actions that have taken place:
No There hss bean s bona fide change in ownership or control of the ineligible Pemon. or Substantial Owner
No Disciplinary action hss been fsken against the individual(s) responsible for the acts giving dss lo the violation
Nc Remedial action has been taken to prevent a recurrence of the acts giving rise to the disqualification or default
No Other factors that the Person or Substantial Owner believe srs relevant.
The Psmon/Substantial Owner must submit documentation to suooori fhe heels of ils mouest for s reduclion or waiver. The Chief Pmcummenl Officer reserves the riohf to make additional inouirie snd reaueat sddllicnel dccumentelicn..
V. Affirmatio The PersoniSubstangai Owner aflirm s Ihpt all statements contained in the AI'fidavit are true, accurate and complete.
Signature: /7 fd Date: jn)14l'r)'ame of Person signing (Print): Roy ~&earn(« TltisI 'Vire Prestrtent end t .PA
subscribed and sworn to bi)Iore me this Its day of tycho~ 20 l'W
x Xbrd.LQ' uNdtary PulHIc S)gnatursg Notary Seal .
Note: The above information is subject to verification prior to lhs award of the Contract.
L I, RIQUET OF ILLINOIS
3;12/22/1 9
SECTION 6
CONTRACT AND EDS EXECUTION PAGE PLEASE EXECUTE THREE ORIGINAL PAGES OF EDS
The Applicant hereby cslttfrss and warrants that all of the statements, certiflcatlons and representations set forth In this EDS are true, complete and corrsd; that the Applicant is In full compliance and will continue to be in compliance throughout the tenn cf the Contract or County Privilege Issued to the Applicant with all the policies and requirements set forth in this EDS; and that all facts and Information provided by ths Applicant In this EDS are true, complete and correct. The Applicant agrees to inform the Chief Procurement Oflicer In wdting if any of such statements, certificatlons, representations, facts or information becomes or is found to be untrue, incomplete or incorrect during the term of the Contract or County Privilege
TASC, Iuc.
Corporation's Name
Prodrigucz@tasc.oTg Email
Date Telephone and Email
Exeoution by Partnership/Joint Venture
Date Telephone and Email
Execution by Sole Proprietorship'rinted
Date Telephone snd Email
Subscribed and sworn to before me this Yf~ day of rf~, 20~.
I My commission expires:
*If the operating agreerrenL partnership agmemsnt or governing documents requiring execution by multiple members, managers, partners, orlolnt venlursrs, please complete and execute additional Contract and EDS Execution Pages.
EDS-15
CERTIFICATE OF LIABILITY INSURANCE 1 06/06/18'HIS
CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS ND RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFINIEATIVELY OR NEGATIVELY A(SEND, EXTEND OR ALTER THE COVERAGE AFFORDED SY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER{S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the cerllflcste holder ls an ADDITIONAL INSURED, the pogcy(les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions Of the policy, certain policies may require an endorsement. A statement on this certlffcate doss Rot confer rights tO the certificate holder In geu cf such endorsement(s).
PRODUCER 708-349-1460 Non Profit Risk Services, Inc. FAX 14504 John Humnhrey Drive 708-349-1760 I UuC. Reit
Or)end Park, IL 80462 Robert GoSnvaux
CONTACT NAME: PHONE Inln. B o. Ball: BMCIL nooRBBBJ
cusmMBR toe TABCiNC
~muRBR n; Great American insurance Co. MBURBR s:Amtrust North America
NAICB
INsURED TASCr Idle. ATTN: MR. ROY FESMIRE 700 S. Cllnton Street CHICAGO, IL 60807 INSURER C:
INSURER D '.
INSURER B
BODILY INJUFIY (Per hereon) $
BGGILY INJURY (Per scddent) $
PROPERTY ohuncd (Psr ecddsnc
X I POLICY IEC;T Lcc AUYGMQBILB LIABILI)Y
ARYAUTO
$
$
B.L. DISEASE - POLICY LIMIT $
X I RETENTloN $ 10,000 WQRKBRB COMPBRBC(IQR AND BMPLOYBRP LIABILITY
B ANY PRGPRIBYGRIPARYNBRIBXBCUYIVB ~ FWC1004943 01 I01/1 8 01I01 /1 9 OFFICBRIMBMBBR BXCLUCBIYI ~ R I n (Mandatory In RR) Y yes, deacdhe under DESCRIPTION OF OPERATIONS hdmr
A Professional Llab PAC0520708 06)21I18 06I21)19
A,Crime Emp Dls/Forg PAC0520708 08/21/1 8 06/21/1 9
UBBQRIphcu oF opERATloNs I Locnholtd! vEHlcLEs (Ruach AUG RU Is), Additional Remarks dehedule. B mors snsca ls rsuulmd) County cf Cook Contract No.1553-14823, Drug Court Assessment Bvaluatoz Servioes, County cf Cook, its employees, officials and commissioners are named as Addi.tional Insured as their interest may appear. The Commercial General Liability shall be primary B non-contributory with any insuxancs or self insurance programs maintained by the County. CERTIFICATE HOLDER
BACHOCCURRBNCB
500,000
CANCELLATION
ODOOOOO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISiONS.County ofCook Office of Purchasing Agent Room 1018 118 N. Clark Street Chicago, IL 60602
AUYKORIXBU REPRESENTATIVE
Robert Golinvaux
1988-2009 ACORD C(3RPGRATIQN. All rights reserved.
The ACORD name and logo are registered marks of ACORDACORD 26 (2009/09)
COVERAGES CERTIFICATE NUII/IBER: REVISION NUMBER:
THIS IS TD CERTIFY THAT THE POLICIES OF INSURANCE LISTED SELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOU(REMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Vtl)TH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE )NSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND COND)TIGRS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Tl I $(IB)f CUBR Boule(/SFF HILIQY BXP LRI YYPB OF INSURANCE IN'un POLICY NUMBER IMMIUUIVYYYI IMMIBGIYYYYI I Lm)rd
GBNBRAL LIABILIIY B/tcu Gcc(MRBRGB I $ 1,000,000
A X COMMERCIAL GENERAL LICBIV)Y X PAC062070S 08/21/1 8 00/21/1 9 ~PRG~IBBB Im I i $ 100,000
c(AIMS-MAGE X OCCUR Mdo Exp (nny owns wm) $ 10 000
PBRBONALBADVIRJURY $ 1rooor000