Contract No. 1143-185BVendor Name: AUTOMOTIVE TECH CENTER

AMENDMENT NO. 3

This Amendmsnt modiles Contract No, 11-53-185B,for AUTOMOBILE MAINTENANCE AND REPAIR FOR ZONE 2'y

and between the County of Cook, lllireis, herein refisned to as "County" snd AUTOMOTIVE TECH CENTER,authorized to do business in the State of illinois hereinager referred to as "Contractor":

RECITALS

Whemas, ths County and Contractor have entered Into a Contract approved by the County Boaid on Octobei 16,2012, (hemlnaftar Isferisd to as the "Contract"), wherein ihe Contractor is lo provide AUTOMOBILE MAINTENANCE

AND REPAIR FOR ZONE 2 (hereinaltsr rsfensd to as'the "Services") from Novembei 1, 2012 through October 30,2015with two (2) one (1)year renewal oplons, in an amount not to exceed $289,100.00; and

Wheisas, Amendment g 1 was executed on April 3, 2014 for an increase of $14900000; and

Whereas, Amendments 2 was executed on July 2, 2014 for an increase of $100 000 00; and

Wheisas, the Contract will expire October 30, 2015, and the agreed upon Services are still require; and

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

Whereas, an Increase M the amount of $465,000,00 is required for the conlnuatlon of Services; and

Whereas, the County and Contractor desire to renew the Contract for twelve (12) months beginning on November 1,2015 through.October30, 2016.

Now therefore, In consideration of mutual covenants contained herein, it is agreed by and between the parties toamend the Contract as follows:

1. The Conbactis renewed through October 30,2016

2. The Contract is increased by $465,000.00 and gte Total Contract Amount is revised fo $1,003,100.00

3. The attached Economic Disckeures Statement kirm is incorporated and made a part of this Contract..

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

In witness whereof, the County and Contractor have caused this Amendment No. 3 to bs executed on the date sndyear hat written below.

County of Cook, illinois

By: ))lab>l~'IÃ3'A>f drxr~p+K 3Chief Procurerne fficer

sr@a.yiCi I's Attorney~ (if applicabM)

'u Tec

Type or print name

//' 5r 0!'Nm +ride

Date: i%et~~ 8, Mi5

acr rnns

CONTRACT NO. 11-63-1858

ECONOMIC DISCLOSURE STATEMENTAND EXECUTION DOCUMENT

INDEX

Section

Instructions

Description

Instructions for Completion of EDS .

Pages

EDSI-ii

MBE/WBE UIizstlon Plan EDS 1

Letter of Intent EDS'2

Petition for ReductionlWsiver of MBE/WBE ParticipationGoals

EDS 3

Certification s EDS4, 5

Economic and Other Disclosures, Affidavit of Child

Support Obligations snd Disclosure of Ownership Interest

Sole Proprietor Signature Psgg

Partnership Mgnature Page

Limited Uability Corporation Signature Page

EDS 133/b/c

EDS 14/a/b/c

EDS 15s/b/c

10

Corporation Signature Page

Cook County Signature Page

EDS 16s/b/c

EDS 17

1.10.13

CONTRACT NO. 11-53-1858

This Economic Dlsdosure Statement and Execution Document ("EDS") is to be completed end executed by everyBiddei on a County contract, every party responding to a Request for Pmpcsals or Request for Qualifications"(Pmposeff), and ofhers as required by the Chief Procurement Officer. If the Undersigned is awarded e contractpursuant to Ihe procurement process for which this EDS was submitted (the "Contract" ), this Economic DisclcrsureStatement and Execution Document Shall stand as ths Undersigned's sxecugon of the Contrscb

Degnlgbns. Capitalized terms used in this EDS arid not othe'rwlse tlsflned herein shall have the meanings given tosuch terms in the Instructions to Bidders. General Conditions, Request for Proposals, Request for Qualifications, orother documents, ss applicable.

"Aff///etsd &ifffy" means a p'erson (ir entity that, direbtly or indirectly: controls the Bidder, iscontrolled by Ihe Bidder, or is, with ths Bidder, under common control of another person or entity.Indicia of contml Include, without limltition,'nterlocking management of ownership: Id'entity ofinterests 'among family members: shared faclliges snd equipment; common use of employees; andorganization of a business eriffty following the ineligibility of 'a buwness entity to do.business withthe County under tHe standards set forth in the Certifications included in this EDS, usingsubstantially the same management, ownership or principals as the ineligible entity.

vS/dder," "Proposer," "Undens/gnsd or "Applicant," ls the person cr entity executing this'EDS.Upon award and execution of a Contract by thi County, ths Bidder, Proposer, Undersigned

'or Applicant, ss ths case may be, shell become ths Contractor. or Contracting Parly.

"Proposal," for purposes of this EDS, is the Undemigned's complete response to en RFP/RFQ, orif no RFQ/RFP wa's issued by the County, the 'Proposal" is such other proposal, quote or offersubmitted by the Undersigned, and in any event a "Proposal" includes this EDS ."Code" means the Code of Ordinances, Cook County, illinois avellabls through the Cook CountyClerk's Offlce website fhtlo://www.cookctvclerk.corn/sub/ordinances.ssc'I, This page csn also bsaccessed by going to www.cookctvdsrk.corn, clicking on the tsb labeled "County BoardProceedings, and then clicking on the link to Cook County Ordinances."

. "Contractor or "Confmcf/nfl Party" means the Bidder, Proposer or Applicant.with whom theCounty hss entered into a CorrtmcL

"EDS"mesne this complete Economic Disdosure Statement and Execution Document, includingall,sections listed in the Index and any attachments.

"Lobby" or lobbying" means to, fcr compensation, attempt to influence s County official crCounty employee with respect to any County matter.

"Lobbyist" means any person or entity who lobbies.

"P/oh!bi(ed Acts" means any of the actions or occurrences which form the basis fordisqualification un'der the Code, or under the Certificstions hereinafter sst forth.

Sections 1 through 3: MBE/WBE Documentation. Sections 1 and 2 must be completed in order to satisfy therequirements of.the County's MBE/WBE Ordinance, as set forth in the Contract Documents, if applicable. If theUndersigned believes s waiver is appmpriate and necessary, Section 3. the Petition for Waiver of MBE/WBEParticipation must bs completed.

Section 4: Certiflcagone. Section 4 sets forth certlilcetions that are required for contracting parties under ths Cods.Exscugon of thle EDS c'onstltutes s wan'aniy that all the statements snd cergilcatlons contained, and all ths factsstaled,.in the Certlllcagons ars true, correct snd complete as of ths date of execution.

Section 5: Economid and Other Discfoaures Statement Section 5 is the County's requkwd Economic snd OtherDisdosures Statsm'ent form, Execution~this EDS consgtutes a warranty that all the information-provided IMhe ——EDS is true, correct snd complete ss of the date of execution, and binds the'Undersigned to the wsrninties,representations, agreements and acknowledgements contained therein.

EDS-i

1.10.13

CONTRACT NO. 11-63-166B

Sections 6, 7, 8, 9:Execution Forms. Ihe Bidder executes this EDS, and the Contract, by completing and signingthine copies of the 'appropriate Signature Page, Section 6 is the form for a sole proprietor Section T is the form forapsrtnership or joint venture; Section 8 is the form for s Limited Liability Corporation, and Secgon 9 ls the form, for acorpomtlon. Proper execution requires THREE ORIGINALS; therefore, the appropriate Signature Page must be filledin, three copies made, and sll three copies must be properly signed, notarized and submitted. The forms may bsprinted and completed b'y typing or hand writing the infcrrcatiori required,

Requimd Updates. The information provided in this EDS will be kept current. In the event of any change In anyinformation provided, including bui not limited to any change which would render Ihaccurate or incomplete anycerdficatlon or statement made In this EDS, the, Undersigned will supplement!his EDS up to the time ths Coumy

. 'akes action, by tiling sn singndsd EDS or such other documentation as is requested.

Additional Information. The Countys Governmental Ethics and Campaign Financing Ordinances, impose cedainduhes and obligations on persons or entities seeking County. contracts, work, business,'or transactions, For furtherinformation please contact the Director of Ethics at (312) 603-4304 (69'W. Washington St..Suite 3040, Chicago, IL60603) or visit our web-site at ww'w.cookcountygov.corn and go to the Ethics'Department link. The Bidder must .

coinply fully with the applicable ordinances.

EDS-li

1.10.13

MBEIWBE UTILIZATION PLAN ISECTION 1i

BIDDERIPROPOSER HEREBY STATES that afi MBEIWBE firms induded in this Plan are certifie MBEsiWBEs by at least one of the entifiea

listed in the General Conditions.

BIDDER/PROPOSER MBEIWBE STATUS: (check the appropriate line)

BkldedPropcssr ls a csrfified MBE or wBE firm: (If so, attach copy of appmprlate Leller of csrfificatlon)

Bi dsrlProposer is a Joht Venture end.one or more Joint Venture panners are cedifled kfiBEs or WBEs. (If so,attach copies of Leher(s) of Certification, a copy cf Joint Venture Agreement clearly descdblng the role of the MSBWBE

firm(s) and ile ownership interest in the Joint Venture and e completed Joint Venture Affidavfi.-available from the OMceof Ccnhnct Compliance)

Bkldsr/proposer ldnot e certtfied MBE or WBEfinn, nore Joint ysntum with MBEiwBE parlnem, but wfil ufifize MBE

and WBE firms either directly or Indiredly In the perfbrmarics of the Contmct, (If so, complete Sscticnd II and ill).

MBEsiWBEc that wfil perform as subcontmctcrs/supffiersfconsultsnts include the hlhwing:

MB~BFlrm; Zmr4 w- Jl) dwS rf/ v Cr

Addreaa; /Kll Adlra~<O i )( ~ kV+r t r~r'. 2 C (V 0&drm

E-maib

contact Person: 4 v'l/ v'. D<ce w. cy'

Phobe: (cn 5 z i fdic yto ryg-~v-

DofierAmountparfidpatlon, 3 /3 0, ~ rp

PercentAmouniofPsrlldpafion.'

2G'Lefier

of Intera sfiached7 No

"Letter of Ced fiicelion sfiachedV No

YesYes

fi. '] DkactParttclpafionofMBEIWBEFlrms ., IndlrectParficlpationofMBEIWBEFlrms

Wham Seals have not been achieved through dhect participation;-Bidder/Proposer sling Include documentation outfihing agoit ~ tortsh)eve Direct Partlctpsfion st ths time of Bhgpropossl submission. Indirect Partlctpsgon wlil only be conrddered ahsr all a(torte toaclilevs Dlmct Partlclpalhm have been mrhausted. Only alter umttsn documentation of Good Faith Egmts is received wfil Indirect

Pmficipation be consld'ered.

MBEIINBE Finn:

Address,

E-maik

Contact Pedon:

Dofisr Amount Parlmipationt S

Percent Amount of Parficlpetlon

/l~l''/

—"Lelmruf In nt sthrched'? 'es ' 'o"Letter of Csrfificatlon afiached? 'es No

Attach additional sheets m needed,

'Additionally, all Lettmn of Intent, Letters of Certification arid documentation of Good Faith Bforts omitted from ttdsbidfprrrposal must be submltlsd to the Olgce of Contract Compliance so as to assure receipt by the

'Contract'orn

plhmca Administrator not later than three (3) business dttys after the Bid opening dots.

EDS-11.10.13

COOK COUNTY GOVERNMENT LETTER OF INTENT IBECTION 2I

M/WBE Finn:

Address:

City/State:

Emag:

Zlp

Fsxr

Certifying Agan'cy:

Csrtlllcation Explra6on Date:

ill / FEIN¹,

// V/Canted Pemon:IContract ¹:

Pmficipstlon: I IDlmct . I jlndimct

WB theM/WEE ilrm be conlradlng'any of the performance of this contract to another finn'I

'g No [ I Yes-Please attach explanation. Proposed Su conlrackrr

The undersigned M/W BE ts prepared to provide the fdlowlng Commod Bes/Services for the above named Pmjecy Contract:

Car~ I vr ce 4"4'CVZA+i4~ E~ref I-'e 4

Indhate Ihs Dagar Amount or Peroentaas, and the Terms of Psvment for the ebovedesdlbed Commodities/ Services',

/3'XVC'If

mare specs Is needed to fu¹y describe AIIIYBE Finn's pmpossd scape of work snd/br payment scbsdWe, slfsch additional sheets)

TNE UNDERSIGNED PARTIES AGREE that this Leiter of Intent wgl become a binding SubcontracL Agreeinent conditioned upon thsBidder/Pmpassr's eipt a sign nir m gm County of Cook. U craig ed 'es do so cerdfy gmt they did not allix theirsignaturesfoth'tocum turNlel re d 'pfronofgervtce/Srp y c ea/ twe camp t

MS,Sl (t/~ ~"

S(gnaturs tysntjrts Bfddstv(pipes+ fy'ape/P~ 4r l w save'" ii . t .,5N'wAd 0 ~ WuJr'v."r

Pdal Name

'eS/,e 8 C'end,ryeFirm Name

'/4~r" k. M f5Dale

Pont Name

Auk m u'fi'Zv ~ex 'IfFinn Name

A7dr~ A /AD / cDate

——Subscdbed andswom befomme --———this~Ay of 'e'rc'

Notary Public

SEAL

—Mubscnbed and.swonvbefore me

this~+ay,of Alar 4,20 I

Natsry Pubgc

SEAL

"OFFICIALEAL'TEVENJ. MILLER

NOTARY PUBLIC, STATE OF ILLINOIS .

I My Commission Expires 3/30/201 8

EDS-2

OFRCE OF CONTRACT COMPUANCE

JACQUELINE GOMEZ

DIRECTOR

116N. Clark, County Building, Room 1020 ~ Chicago, glinois 60602 ~ l312) 603-5502

TONE pftECKufIEEKLE

PRESIDEN'I

Cook County Board

of Commlsslonms

RICHARD R. BOYKIN

1st Distria

ROBERT STEELE

2nd Dlstda

JERRY BUTLER

3rd District

January 28, 2015

Ms. Leslie A. Cesario, PresidentLeslie A. Cesarlo, Ltd.

1313Mamngo Court

Naperville, IL 60564-9505

Annual CeltiTication Expires: January 28, 2018

Dear Ms. Cesarlo:

Congratulafions on your continued eligibility for Ceffification as a Womendiwned Business EnterpriseONBE) by Cook County GovemmenL This Certiiication is valid until 'January 12, 2018.

STANLEY MOORE

4th Distria

DEBORAH SIMS

5th Distiict

JOAN PATRICIA MURPHY

6th District

JESUS G. GARCIA

7th District

LUIS ARROYO JR6th District

PETER N. SILVESTRI

9th Distria

BIBDGET GAINER

11th District

JOHN A FRITCHEY

12th District

LARRY SUFFREDIN

Uth Distria

GREGG GOSUN

14th Distrid

TIMOTHY O. SCHNHDER

15th District

As a condition of confinued Celtificalion, you must file a oR'e.Certification Affidsvit" within sixty (60)business days prior to the Annual Certification Expiration date. Failum to file this A%lavlt shall resultin the termination of your Certification. You must nofify Cook County's Ofiice of Contract Compliance of anychange in ownership or control or any other matters or facts affecting your firm's efigibility for Celtificafionwithin fifteen (15)business days of such change.

Cook County Government may commence action to remove your firm as a certified vendor if you fail tonotify us of any changes of facts affecfing your firm's Cerfilicstion, or if your firm othenvise fails to cooperatewith lhe County in any inquiry or investigation. Removal Of your status may also be commenced if your firmis found to be involved in bidding or contractual irregutarities.

Your firm's name will be listed in Cook County's Directory of certiTied firms in the folhwing area(s) ofspecialty.

Professional Bervlce: Certified Public Accounting snd Auditing Services

Your firm's parlicipafion on Cook County contracts wfil be credited toward WBE goals in your area(s) ofspecialty. While your participation on Cook County contracts is not limited to your specialty, credit towardWBE goals will be given only for work done in the specialty category.

Thank you for your continued interest in Cook County Government's Minority, Women and VeteranBusiness Entelprise Pmgrams.

Sincerely,

Jacqueline GomezContract Compliance DirectorJG/ek

JEFFREY R. TOBOISKI

16th Distrid

RKABD 6 ANN DDDDY GDBAIAN

17th Distrid

$ Fiscal Responsibility f Innovative Leadership II) Transparency Ek Accountability f«J improved services

PETITION FORWAIVER OF MBE/WBE PARTICIPATION ISECTION 3I

A, BIDDER/PROPQSERHEREBY REQUEST

WAIVER

(ON (PARTIAL.MBE and/o

% of Reduction for MBE PaWcipati

%of Reduction for WBE Participation

B. REASON FOR FULL/REDUCTIONWAIVER REQUEST

L WBE WAIVER

IPAT ION)

BlddedProposer ihall check each item appgcable to its reason foi a waiver request. Additlonallv. suooortlnc doc umslitaflon shellbs submitted with this recuesk If such suooortinc documenlafion cannot be submitted with bid/orooosal/ouolation. suchdocumentation shall be submitted directlv tc the Oflice of Contract Comoliance no later than three (3'I davs from the date ofsubmission

date.'I

) Lack of sullldent qualifled MBEs and/or WBEs capable of providing Ihe goads or services required by the conbact,(Please explain)

{2}The specigcafions and necessary requirements for performing the contract make it impossible or economicallyinfeasible to divide the contract to enable the contractor to utilize MBEs and/or WBEs in accordance with theapplicable Parficipation. (Please explain)

(3) Price(s) quoted by potential MBEs and/or WBEs are above competitive levels and Increase cost of doing businesssnd would make acceptance of such MBE and/or WBE bid economically impracticable, taking into consideragonthe percenhrge of total contract price represented by such MBE and/or WSE bid, (Please explain)

(4) There are other relevant factors making it impossiMe or economically infeasible to uhlize MBE and/orWBE firms. (Please explain)

C, GOOD FAITH EFFORTS TO OBTAIN MBE/WBE PARTICIPATION

(I) Made timely written solicitakon to identified MBEs and WBEs for'ubTizali'cn of goods and/or services;and provided MBEs and WBEs with a timely opportunity to review and obtain relevant sperdgcations,

- terms and conditions of the proposal to enable MBEs and WBEs to prepare an informed response tosolicitation. {Please attach)

(2) Followed up initial solicitation of MBEs and WBEs io determine if firms ars interested in doingbusiness. (Please attach)

{3) Advertised in s timely manner in one or more daily newspapers and/or trade publication for MBEs andWBEs for supply of goods and seniices. (Please attiich)

(4) Used ths services and assistance'of the ONge of Contract Compliance slslf, (Please explain)

(5) Engaged MBEs & WBEs for indhsct participation. (Please explain)

D, OTHER RELEVANT INFORMATION

Attach any other documentation relative to Good Fai(h Efforls in complying with MBE/WBE parficipation,

EOS-31.1Q13

CERTIFICATIONB(SECTION at

THE FOLLOWING CERllFICATIONS ARE MADE PURSUANT TO STATE LAW AND THE CODE. THE UNDERSIGNED IS'AUTIONED TO CAREFULLY READ THESE CERTIFICATIONS PRIOR TO SIGNING THE SIGNATURE PAGE. SIGNINGTHE SIGNATURE PAGE SHALL CONSTITUTE A WARRANlY BY THE UNDERSIGNED THAT ALL THE STATEMENTS,CERTIFICATIONS AND INFORMATION SET FORTH WITHIN THESE CERTIFICATIONS ARE TRIJE, COMPLETE ANDCORRECT AS OF THE DATE THE SIGNATURE PAGE IS SIGNED. THE UNDERSIGNED IS NOTIFIED THAT IF THE

'OUNTYLEARNS THAT ANY OF THE FOLLOWING CERTIFICATIONS WERE FALSEI Y MADE, THAT ANY CONTRACTENTERED INTO WITH THE UNDERSIGNED SHALL SE SUBJECT TO TERMINATION,

PERSONS AND ENTITIES SUBJECT TO DISQUALIFICATIONi'o

psrsbn or business entity shall be awarded a contract or sub-contrsct, fcr a period of five (5) years from the date cfconviction or entry of a plea or admission of guilt, civil or criminal, If that person or business entity:

1) 'as. been convicted of an act committed, within ths State of lllinoi's, of bribery or attempting to bribe an officeror employee of a.unit ef slate, federal or local government or school district in the State of illinois in that

'fficersor erhployee's oScial capaoity;

2) Has been convicted by federal, stets or local government of an aci of bid-rigging or attempting to rig bids asdefined in the Sherman Anti-Trust Act and Clayton Act. Act. 15 U.S.C. Section 1 et seq J

3) Has'been convicted of bid-rigging or attempting to rig bids under the .laws of federal, state cr localgovernmsnh

4) Has been convicted of an act'committed, within the State, of price-fixing or attempting to fix prices as definedby ths Sherman AntiTrust Act and the Clayton Act 15 USC. Secfion 1, et sequ

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

6) Has bse'n convicted of defrauding or attempting to defraud any unit of state or local government or schooldistrict within the State of Slinois:

7) Hss made'an admission of guilt of such conduct as set forth in subsections (1) through (6} above which .admission is s matter of record, whether or not such person or business entity was subject to prosecution

for'hs

offense or offenses admitted to; or

3) Has entsmd a plaa of nolo contendere to charge of bribery, price-tlxlng, bid-rigging, or freud, as set forth insub-paragraphs (1) through (6) above.

In the case of bribery or attempting to bribe, a business entity may not be awarded a contract if ad offichfi, agent oremployee of such buNiness entity committed the Prohibited Act on behalf of the business entity and pursuant to ths

. direction or authorizafion of an officsr, director or other responsible otticial of the business entity, and such Prohibited,Act occurred within three years prior to the awaid of the. contract. In addltBn, a business entity shall be disqualified ifan owner, partner or'shareholder controlling, directly or indirectly, 20 'k or more of the bueiness entity, or sn.ofgcer ofths business entity has performed any Prohibited Act within five years prior to the award ofihe Contraot.

THE VNDERSIGNED HEREBY CERTIFIES THAT: The Undersigned hss read the proviNions of Section A, Personsand Entltiss Subject to Disqualification, that ths Undersigned has not committed any prohibited Act set forth in SectionA, and that award of the Contract to the Undersigned would not violate the provisions of such Section or of the Code.

. B. ')D-RIGGING OR BID ROTATING

THE VNDERSIGNED HEREBY CERTIFIES THATQn accordance wilh 720 ILCS 5r39 E-11, neither the Virdsrsignednor eny Aiffflafsd Entity is barred from ami'id of this Coninicf as s result of s conviction for. Ihe violation ofSfsls Iews——pmhibiffng-hid-nggisg. or-hid-rotating.

C. DRUG FREE WORKPLACE ACT

'HE UNDERSIGNED HEREBY CERTIFIES THAT: The Undersigned will provide a'drug free workplace, as required byPublic Act 86-1459 (30 ILCS 580/2-11).

EDS-4

1.10.13

D. DEUNQUENCY IN PAYNIENT OF TAXES

THE UNDERSIGNED HEREBY CERTIFIES THAT: The Undersigned is not an owner or e Party responsible for thspayment of any tsx or fee admlnistsmd by Cook Counb, by s local municrpaiity, or by the iiikrofs Department of Revenue,whkh such tsx or fee is'elinquent, such as ber award of a contract or suhccntmot pursuant Io the Code, Chapter 34;Section 34-129.

E..HUkfAN RIGHTS ORDINANCE

No person who is s party to a contmct with cook. county ('counhr) shall engage In unlawful discrimination or sexualharassment against any Individual In the terms or 'condlgons of employment, credit, public accomrnodagons, )rousing', or

'cesor programs (Code Chapter 42, Secdon 42-30 et seq).provision of County facgtles, serv

F. ILUNOIS HUMAN RIGHTS ACT

tHE UNDERSIGNED HEREBY CERTIFIES THAT,: if is'in compliance wgh fhs the illinois Itumsn Rights Act (775 ILCS52 f05), and agrees'fo abide by the mqulrsmenis of the Act ss pert of Its contractual obllgalfons.

G. )VIACBRIDE PRINCIPLES, CODE CHAPTER 34, SECTION 34-132

If the primary contractor currently conducts business operations in Northern Ireland, or Will conduct business dwing theprc)ected duration of a County contrscb the primaqr contractor shall make all reasonable and goo'd faith efforts t'o conducteny such business operations in Nodhem Ireland in accordance with the ktscBride Prindples for Northern ireland asdetlned In llltncis Publfc Act 86-1390.

H. LIYING WAGE ORDINANCE PREFERENCE (COOK COUNTY CODE, CHAPTER 34, SECTION 34-127;

The Code requires that a living wage must be paid to individuals employed by a Contractor which has a County, Contractsnd by all subcontmctcrs cf such Contractor under a County Contract, throughout the duration of such County Contract.'The amount of such living wage is determined from time to time by, and is available from, ths Chief Financial OIEcer.of theCounty,.

For purposes of this EDS Section 4, H, "Contract" means any written agreement whereby the County is commmed to ordoes expend funds in connection with the agreement or subcontrart thereof. The term "Contract" as used in this EDS,Secgcn'4, I, spsci5cally excludes contracts with the following:

1) Not-For ProSt Organizations (dstkted as a corporation having tax exempt status under Section 601(C)(3)cf theUnited State Internal Revenue Code and recognized pnder the illinois State not for-protlt law);

2) Community Development Block Grants;

3) Cook Ccurdy. Works Dsparimenl;

...4). Shetttfs Work Alternative Progmm; snd

5) 'epartmentof Corre'ction inmates.

1.10.13

REQUIRED DISCLOSURES fSECTIQNCI

1.'ISCLOSURE OPLOBBYIST CONTACTS

List all persons or entitles that have made lobbying contacts on your behalf with mspect to this c'outrank

Name Address

yV/ /~

2. LOCAL BUSINESS PREFERENCE DISCLOSURE; CODE, CHAPTER 34, SECTION 34-151(p)

"Local Business" shall, mean. a person authorized to transact business In this Slate and having s bona fide'stablishment fortransacgng business located within Cock County at which it was actually tmnsacting business on the date when siiy competitivesolicltatlon fcr a public contract is first advergsed or announced and further which employs ths majority of its regular, full time workforce within Cook County, induding a foreign corporation duly aulhoriized to transact business in this Slate and which has a bonafide establishment for transacang business located within Cook County at which it was actually'transacting business on the datewhen any competitive solicitation for a public contract is first sdvertised or announced and further which employs the maJority of itsregular. full lime work force within Cook County..

a) ls Bidder a "Lo'cal Business" as defined sbcve2

Yes: X No

b) If yes, list business addresses wilhin Cook Couniy:

c) Doss Bidder employ the majority of its regular full fime workforce within Cook County2

Yes: Y No:

3 'HE CHILD SUPPORT ENFORCEMENT ORDINANCE (PREFERENCE (CODE CHAPTER 34( SECTION 34366)

Every Applicant for a County Pmiilege shell 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 CountyPrivilege, and msy revoke any County Privilege.

All Applicants are required to'review the Cook County Affidavit of Child Support Obligations attached to this EOS (EDS;8)and comp)ate the foJJcwittg)raced u pon the definitions and other Information Induded tn such Atgdavit

EDS-6

t.to.t3

4. REAL ESTATE OWNERSHIP DISCLOSURES

The Llnderslgned must indicate by checking the appropdate pmw'sion below and providing ail required information that either,

a) . The following is a complete list of all real estate owned by ths Undersigned In Cook County

PERMANENT INDEX NUSSBER(S)

(ATTACH SHEET (F NECESSARY TO LIST ADDITIONAL INDEXNUMBERS)

b) ~lhe Undersigned owns no real estate in Cook County.

5. 'EXCEPTIONS TO CERTIFICATIONS OR DISC'LOSURES

If the Undersigned is unsbls to certify to any of the Certificaticns or any other statements contained in itss EDS and not explainedelsewhere in this EDS, the Undersigned must explain below:

If the letters, "NA", the word "None" or "No Response" appears above, or if the space is left blank, it will be conclusively presumed. that the Undersigned csrlitled to sll Certigcaiions and other 'statements contained In this EDS,

EDS-71.10.13

COOK COUNTY. DISCLOSURE OF OWNERSHIP INTEREST STATEMENT

The Cook County Code of Onfinances (52-B10 ef seq.) requires that any Applicant for any County Action must disclose informationconcerning ownership interests in the Applicant. This Disclosure of Ownership Interest Statement must be completed with allinformation current ss of ths date this Statement is signed. Furthermore, this Statement must be kept current, by filing an amendedStatement, until such 'time asthe County Board or County Agency chal take action on ths application.,The IIIfarmetlort contained fnthis Statement will ba maintained in a database and made available for public viewing.

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

"AppiloanF means sny Entity or persohr'nsklng an spplic'ation to the County for sny County Action.

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

"Entity" or Legal Entity" means a sole proprietorship, corporation, partne'rship, association, business trust, estate, two or morepersons having a joint or common interest, trustee of a land trust, other, commdrcisl or legal entity or bny beneficiary or bsnstlciariesthereof.

''

This Disclosure of Ownership Interest Statement must bs submitted by:

1.An Applicant for County Action and

2. An individual or Legal Entity that holds stock or a'beneficial internet in the Applicant snd Is listed on the Applicant's Statement (a"Holder" ) must gie s Statement and complete gt only under Ownership Interest Declaration.

Please print or type responses clearly snd legibly. Add additional pages If needed, being careful to identify each portion of the form to'which each sddigonai page.rsbtrs.

This'Statement ie being made by the [g ]Applicant or [ ] Stock/Beneficial Interest Holder

This Statement ls an: [ Original Statement or [ ]Amended Statement

. Identifjng Irtformation:

Name yi yi Tp~vr Car W D/B/A; w r

Street Address: FZ~ A 4"4/ @cr

EINNO 4 Io +>4'+)~City'van

+4 ry Cy r State: Z ~Ztp Code: 6 6"2 < +-

Phone No.:(~~8/ ~ P ~-/~/6

Form of Legal Entity:

[ ] .SolsProprletor, [ ] Partnership Ib]([ Corporation [ ] Trustee of Lend Trust

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

[ ] Other (describsj

EDS-9

1.10.13

Ownership Interest Declaration:

Ust the name(s), address, and psrcenl ownership of each individual and each Entity having a legal or beneficialinterest {including ownership) of more than five percent (5%) in the Applicant/Holder.

Name ..Address Percentage Interest In

Applicant/Holder

P+f/i'e- r'Wc'7rcC'(cl 5 /wee rr(rkyae cj:8 crfrsrg- pls'ee4v gee ]c/Pg Cire 8l,t/ /fisher .3C ifdcdet) f

Ar'Vc U ccPXe Bred OV freerc cShcLr cit[Z crore ..Vi, /ecri>rf

2. 'f the interest of any individual or any Entity listed in (1)above is held as an agent or agents, or a nominee ornominees, list the name and address of the principal cn whose behalf the interest is held.

Name of Agent/Nominee'.

Name of Principal Principal's Address

X~A'/rf

r'stheApplicaniconstructivelycontrolledbyanotherpersonorLegalEntity7 [ ]Yes [ +]NoIf yes, state the name, address and percentage of beneficial interest of such person or legal entity, and therelationship under which such control is being or may be exerdssd.

Name . Percentage ofBeneficial Inisrest

Relationship

Declarafion (check the applicabls box):

[ ] I slate under oath that ths Applicant has withheld no disclosure'as to ownership interest in tha Applicant nor eservsdany Information, data or plan as to the intended uss or purpose for whbh the Applicant seeks County Board or otherCounty Agency, action.

[g] I state under oath that the, Holder has withheld no disclosure as to ownership interest nor reserved any informationrequired to be disdosed.

PlSMkcc~ ~'ccdt CrNam o: ihoiized ppl old/ Representative (please prfnt or type)

'ignature

tI t.'I D viI ]-- ws~wPw3-Q —-8&s;r~--

E-mail address Phone Number

Subscdibsd to and sworn before methis p r e day of~4 20 /~ My ~ w; .:2/roy pr/

8'DS-10

Notarv Public SicnstureNotary S.'~

cGFFIOW (]]BAL"875/IP] c] Ml[ I KR

NOTARY PUBLIC, STATS QF ILLINOIS

Niy Cammission Sxpircs S/30/2018 ~1p 15

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

CHICAOO, ILLINOIS 60602312/6034304

312/603-9988 FAX 312/603-1011TTIITyD

RA MII,I Ar. RIII,A TIONSIIIP OISCI;ARURR PR OVISI OI4

Section 2-582 of the Cook County Ethics Ordinamce requires any person or persons doing business with Cook County, uponexecution ofa contract with'Cook County, to disclose to the Cook County Board ofEthics the exlsten'ce offifmilial

relationships they may have with all persons holding elective office in the State of Illinois, the County ofCook, or in anymunicipality within the County ofCook

The disclosure required by this section shall be filed by Janus'ry I ofeach calendar year or within thhty (30) days of theexecution ofany contract or lease. Any person filing a late discleime sthtement after January 31 shafi be assessed a late filingfee of$100 00 per day that the disclosure is Iase. Any person found guilty ofviolating any provision ofthis section orknowingly Sing a false, inisleading, or incomplete disclosure to the Cook County Board ofEthics shall be prohibited, for aperiod ofQnue (3)years, fiom engaging, directly or indirectly, in any business with Cook County. Note: Please sec Chapter 2Administnaicn, Article VII Ethics, Section 2-582 of the Cook County Code tc view the full

provisions�'cf

ibis section.

Ifyou have questions coricerniug this disclosure requirement, 'please call the Cook County Board ofEthics at (312)603-4304.Note: A curreat list of ccctratscts doing business with Cook Couniy is availabib via the Cook County Bcaid ofBhics'ebsfte 'aq

http: //www.ceckccuatygcv.cern/taxonomy/cthks/Listings/cc ethics VeadcrList, pdf

IIRRINITIIIhigi

"Calendar year" means Ianuary I to December 31 ofeach year.

"Doing bas(sess" for this Ordinance provisioa means any one or any combination of leases, contracts, or purchases to or withCook County or any Cook County agency in excess of$25000 in any calendar year.

is related to an official or employee ss spouse or any ofthe folloviing, whether by"Eatntltal relationship" tneiius a person whoblood, manhole or adoption:.~ Parent

'Child

~ Brother~ Sister~ Aunt~ Uncle~ Niece

~ Grandparent~ Grandchild~ Father-in-law~ Mother-in-law~ Son-in-law

'

Daughter-in.law~ Brother-in-law.~ Sister-in-law

i Stepfather~ Stepmother~ Stepson~ Stepdaughtpr~ Stepbrother~ Stepsister .

~ Half-brother~ Half-sister~ Nephew

"Parson" means any individual, entity, corporation, partne'rship; firm, association, union, trust, estate, as well as any parent orsubsidiary ofany of the for'cgoing, and whether or not operated for profit,,

1.10.13

~nlvitt.tat, t<KLntTntvnBTP ntSCI.BSttbtR FARM

,pursuant ro Section 2582 of tlw Cook County Stblc s Ordinance, aaypsrecu v do/ng Eiurterrr 'itli Cuuk County must disdlose,'o the Coolt County baird of&1dcs, the wtisrence ofjtvntt/ct ratcrkenhipr to any person holding elective offic ln tft's Stan ofIiiinot t, Cook Coukq ,

'w trt auy municipality within Cock County. Please print yuw responses,

Wamwof Owner/Bmployan 0WA a 'Qr frt Thee!

Suriocrs Entity Serac:~~~~y/aa-, Phone: / '7 P /t /'. ( A 'W'/~

The folio wing thmWai relgtship exists bsttveen the owner or any amp tdyva of tha bushmte auttty contr aotnd to 'do

business with Cook County ead any pcrfon bctdtug cteettve olfico'in the State cI Ifliudis, Cook Coumy, or iaauy'unicipalitywithin Cock County.

Owner/Employee blame: Related to: Relstioaddp;

4.

3.

Ifmorc space is needed, ettec'b an addiuouai sheet following tbv above ftumaL

There ls ee ftcnilial tohtdonship that athta bc(wean tha owner o8 eny mnployee cf the business cmlty

conmuncd to do business 'with Cook County en)any person holding elective ofdce itl the Sans ofltbnois, CooltCoua'ty, or in eny

municipality�

'withhi Cook County.

e bstst of my owkutge and belisf, the informdtion provided abuse is trueend cutup)ete,

q'\

/t/ v+~p~d A M/'SpOwggr/BmtIjtoyee,'s i anne 'adt~ b Ibu. d 2f d / '- PPV WE/CA . tt /Ma Nouaypuhbc in snd for~&/ i 'ounty~=ca,m.~(Stge stum)

NOTARY P( fsccv ..Opp Ct/tL 86/tL j MyConmdmicn oxPtret ~Z3 ty/M W~STEV 'J~ILLEFI ..

ttOT/tRV PUSK)C, STATE OF iLL'i

~: Completed ih m~ttfg $ 686 Ihtt Ixccutioa ofate contract or lasso with Cook County aad shauid he malted

Cook County Board of'Sthtcs .6p tr/est%ashtngtuu Street,

Suite 3066- . Chicago,'Itttnets 6D602

ED8-121.10.13

T8 38v/d 90/vS J.33 IB l3dd00 8LT879uEL6 88:trT. 8885/98/T8

SIGNATURE SY A SOLE PROPRIETOR

(SECTION 6)

The Undersigned hereby cerhfies and warrants: that all of the statements, ceitificefiions and representations set forth irl illis EDSare true, complete and cormcLi that the Undersigned is In full compfiance snd wfil continue to be in compliance thrcughota fiie tennof ths Contract or County Privilege issued to the Undersigned with afi ths pollciss and requirements set forth In this EDS; and thatafi facts and Information provided by ths Undersigned In this EDS ars true', complele and 'correct The Undersigned agrees foinform the Chief Procurement Officer in writing if any of such statements, cerlificstions, representations, facts or information

becomes or is found to bs untrue, incomplete or incon set during ths term of ths Contract cr County Privfiege.

. BUSINESS NAME:

BUSINESS ADDRESS:

BUSINESSTELEPHONE:

FEIN/SSN:

COOK COUNTY BUSINESS REGISTRATIONNUMBER.'AX

NUMBER:

SOLE PROPRIETOR'8 SIGNATURE:

PRINT NAME:

DATE; '.

Subscribed to end sworn before me this

day of , 20

My commission expires:

Notarv Public Slonature

Notary. Seal

EDS-13. 1.10.13

SIGN@Tuna RY A SOLE PROPRIETOR

(SECTION 6)

The Undersigned hereby cerfifies and warrants: that all of the statements, cerfjfications and rspmsentalions sst forth in this EDBare true, complete snd correct; that the Undersigned is in full compliance and will continue to bs in comp)amos throughout the tsmIof ths Contract or County Privilege issued to the Underelgned with all the policies and rsrtulrements set forih In this EDS; end that.all facts and Information provided by the Undersigned in this EDS are true, compiets snd 'correcL The Undersigned agrees to .jnform the Chief procurement ONicer In writing if any of such statements, cerfjfrcafjcns, representafions, facts or informationbecomes eris found to be untrue, incomplete or incorrect during the term of the Contract or County Privilege.

BUSINESS NAME:.

.BUSINESS ADDRESS:

BUSINESSTELEPHONE.'EIN/SSNr

COOK COUNTY BUSINESS REGISTRATIONNUMBER.'AX

NUMBER

SOLE PROPRIETOR'S SIGNATURE:

PRINT NAME:

'ubscribed to and sworn before me ibis

'sy

of , 20My commission mpires:

Notsrv Public Slonstum

Notary Seal

EDS-13b

1.10.13

SIGNATURE BYA SOLE PROPRIETOR

(SECTION 6)

The Undersigned hereby csifffies snd wsrrsrds: ihat all of the statements, ceitificsgons snd reprssi:ntalions set forth in this EDSare true, complete snd correct; ihat ths Undersigned is in full compliance and will continue to bs in compliance throughout the termof ths Contract or County Privilegs issued to the Undersigned with sli the policies and requirements sst forth In this EDS; snd thatall facts and information provided by the Undersigned In this EDS are true, 'complete and sorrecL Ths Undersigned agrees toinform the Chief Procurement Officer in wnsng if any of such statements, cerfiffcalions, representations, facts or informationbecomes or is found to be unhue, incomplete or incorrect during Ihs term of the Conlrsct or County Pdwlege.

BUSINESS NAME:

BUSINESS ADDRESS: .x X llÃ

BUSINESS TELEPHONE;

FEIN/SSN:

AXNUMBER

COOK COUNTY BUSINESS REGISTRATION NUMBER:

SOLE PROPRIETOR'S SIGNATURE:

PRINT NAME:

DATE,'ubscribed

to and sworn before me this

day of , 20My commission expires:

Notarv Public Sicriature .Notary Seel

EDS-13c1.10.13'

SIRNATURE Rv A PARTNERSHIP fsND/OR A.lraNT VRNTUREI

{SECTION 7)

The Undersigned hereby cerfiiies arKI warrants: that all of the statements, certificsfrons, and rspresentafions set forth in this EDSire true, complete snd conscbl that the Undersigned is in full compliance and,will cafrtlnue to be in compliance throughout lbe termof ths Contmct or County Privilegs issued Ia the Undersigned with all the policiss and requirements set forth in this EDS; end that'll of the facts snd informagon provided by the Underdigned in this EDS are true, complete and correct. The Undersigned egress tojnform the Chief Procurement Oificer in wriTing if any of such statements, ertiiications, representations, faots or information

. becomes or B found to be untrue, incomplete ar incorrect during the tenn of the Cantract or County Privilege..

BUSINESS NAME:

BUSINESS ADDRESS:

BUSINESS TELEPHONE:

CONTACT PERSON'.

FAX NUMBER:

FEIN/SSN:

"COOK COUNTY BUSINESS REGISTRATION NUMBER:

SltgNATURE OF PARTNER AUTHORIZED TO EXECUTE CONTRACTS ON BEHALF OF PARTNERSHIP:

Oats:

Subscribed.to and sworn behre me this

day of ,20My commission expiree:

X Notarv Public Sianature

Notary Seal

'ttaclj hersta a pakneishlp resolution or other document authorlalng the Individual signing this Signature Pageto so sign on behalf of the Paknsrshfp,

EDS-14a1.10.13

SIGNATURE SY A PARTNERSHIP'(AND(OR A.IOINT VENTUREI

(SECTION 7)

The Undersigned hereby certifies and warrants: that all of the statements, certifications, and reprssentalicns sst foHh in th!s EDSera true. complete end correct; that the Undersigned is in full compliance and will cohficue to bs in compliance throughout the term.of the Contract cr County. Privilege issued lo the Undersigned with all the policiss and requirements set forth in this EDS; end thatall of the facts end 1nfolmstfbn provided by Ihe Vridersigned in this EOS ars true, complete and conscL'he Undersigned agrees toInform the Chief Procurement QNcer in witdng if any of such statements, cerlificafions, representations, facts or information

becomes or is found to be untrue, incomplete or incon ed during the term of the Ccnbact or County Pmgsge..

BUS)NESS NAME:

BUSINESS ADDRESS:

BUSINESS TELEPHONE

CONTACT PERSGN

FAX NUMBER:

FEIN/SSN'I

*COOK COUNTY BUSINESS REGISTRATION NUMBER;

SIGNATURE OF PARTNER AUTHORIZED TO EXECUTE CONTRACTS ON BEHALF OF PARTNERSHIP:

BY:

Date:

Subscribed to end.sworn before me this

day of , 20

My commission expiissi

Notary Public SionatureNotary Seal

Attach hereto s partnership resolution or other document euthorlaing the individual signing this Signature Pageto so sign on'behalf of the Pednerehip..

EDS-14b1.10.13

SIGNATURE BYh PARTNERSHIP IANO/OR A JCMNTVENTUREI

(SECTION T)

The. Undersigned hereby cerlifies snd warrants: Ihst af of the statements, csriigcasons, end representations sst forth in this EDSara true, oomplete and consct; that ths Undersigned is ln full compliance and wig condnue to be in complian'cs throughout 6Ie termof the Contract or County Privgege Issued to the Undersigned stth all the pogcles and requirements set forth ln this EDS; snd thatall of the fash snd informsdon provided by ths Undersigned In this EDS srs true, complete and corrscL The Undersigned agrees toinform the Chief Procurement OScer in writing if any of such statements, 'cerbTicefcns, reprssentadons, feds or informationbecomes or is found.to be unbue, incomplete or incorrect during the term of the Contract or County Privilege..

BUSINESS NAME

BUSINESS ADDRESS: WYH

BUSINESS TELEPHONE:

CONTACT PERSON.

COOK COUNTY BUSINESS REGISTRATION NUMBER:

FAX NUMBER:

FEIN/SSN:

SIGNATURE OF PARTNER AUTHORIEED TO EXECUTE CONTRACTS ON BEHALF QF PARTNERSHIP:

*BY.'ate;

Subscribed to and sworn before me this

day of ,20My commission expires:

Notarv PublicSionsture'otary

Seal

* . Attach hereto a partnership resoludon or other document authorlzlngths individual signing this Signature'Pageto so sign on behalf of the Partnsmhip.

EDS-1ac1.10.13

SIQNATIIRE BY A LisIIITED LIABILITY CORPoRATION

(SECTtON 8)

The Undersigned hereby ceriifiss end warrant: amt all of the statements, certificsgons, and representations set forth ln INs EDSare true, complete and correct; that the Undendgned is In full compliance snd will continue tc be in compliance throughout Ihe termof the contract or county Privilege issued tc ths Undersigned with all the policies and requirements set forth In tlils EDs; end thatall of the fscu.snd Infcrmason provided by the Undersigned in this EDS ars true, complete snd corrscL Ths Undersigned agrees toinform the Procurement Director in writing if any of such statements, certiTications, representations, fade or information becomes oris found Io be untrue, incomplete or incorrect during the term of the Contract or County Privilege.-

BUSINESS

NAME'USINESS

ADDRESS'.

BUSINESS TELEPHONE:

CONTACT PERSON:

FAX NUMBER: /E/E7

FEIN:

IVIANAGING MEMBER:'

CORPORATE FILE NUMBER:

MANAGING MEMBER:

SIGNATURE OF MANAGER:

ATTEST:

Subscribed and sworn tc before me this

day of , 28

Notary Public Signature Notary Seal

If the LLC is not registered in'the State of lltinois, a copy of a current Certificate of Good Standing fromthe state of incorporation must be submitted with this Signature Page.

ee 'ttach either a certified copy of the by-laws, articles, resolution or other authol'ization demonstratingsuch persons to sign the Signature Page on behalf of the LLC.

EDS-1Sa1.10.13

SIGNATURE BY A LulsITED LIABILITY CORPORATION

{SECllON 8)

The Undemigned hereby cerblies and warrants:.that ag Cf the statements, ceriificagons, and representatons set forth in this EDSare true, complete and corrsrri; that the Undersigned is in full compliance and will congnue tc be in compliance throughout the termof ther Corrirsct cr County Privilege issued to the Undersigned with ag the policies and requirements set forih in this EDS; snd thatag of the facts end information provided by ths Undersigned in tiris EDS are true, complete and cosset. The Undersigned agrees toinform the Procurement Director in writing if any of such statements, cerlillcations, repmsentstions, fads or information becomes oris found to be untrue, incomplete or Incorrect during the term of the Contract or County Privilege.

BUSINESS.NAME

BUSINESS ADDRESS

BUSINESSTELEPHONE'.

'r

FAX NUMBER:

CONTACT PERSON:

FEIN:"

MANAGING MEMBER:

*CORPORATE FILE NUMBER: .

MANAGING MEMBER:

SIGNATURE OF MANAGER:

ATfEST:

Subscribed end sworn to before me this

'ay

of :20

Notary Public Signature NotsIy Seel

lf the LLC is not registered in the State of Illinois, a copy of a current Certificate of Good Standing fromthe state of incorporation must be submitted with this Signature Page.

;- Attach either a cert{fle copy of the by-laws, articles, resolution or other autho'rization demonsti'sting.such. persons to sign the Signature Page, on behalf of the LLC.

EDS-1Bb

1.10.13

SIGNATURE BY A LIIIITED LIABILITY CORPORATION

tSECTIQN 8)

The Undemigned hereby cssges and warrants: Ihat as of the statements, certifica5ons, snd representatons set forth in this EOSsre true, complete and conact that the Undersigned is In full compliance and wfl consnue to be in compliance throughout the termof the Contract or County Pmiilsge issued to the Undersigned with af the pofcles and requirements set forth ln this EDS; snd thatsll of the fa'cts and Informatcn provided by ihe Undersigned In this EDS are true, completa and corrsd. The Undersigned agrees toinform Ihe procurement Direcarr in writing if any of such statements, certifrcationa, representations, arete.cr information becomes oris found to be untrue, incomplete or incorrect. during the term of the Contract or County

Privilege.'USINESS

NAME:

BUSINESS ADDRESS:

BUSINESS.TELEPHONE:

/.FAX NUMBER: .

CONTACT

PERSON''ANAGINQ

MEMBER:,

*CORPORATE FILE NUMBER:

MANAGING MEMBER:

..SIGNATURE OF MANAGER

ATTEST:

subscribed and swum to before me this

day of .20

Notary Public Signstuia Notsy Seal

If the LLC is not registered in the State of illinois, s copy of a current Certificate of Good Standing fromthe stata of incorporation must be submitted with this Signature Page.

Attach efther a certified copy of the by-laws, arttcles, resolutiod or other authodlzatiOn demonstrating.'u'ch persons to sign the Signature'Page on behalf of the LLC.

EDS-15c1.10.13

SIGNATURE BY A CORPORATION

(SECllON 9)

The Undemigned hereby cur!ilies and warrants: that sfi of the statements, certificefions, and representations set forth in this EDB

ars true, complete and correct; that the Undersigned is in full compliance snd will continue to bs in oompliance throughout ths term

of ths Contract or County Privfisge issued to the Undersigned vtth afi the policiss and requirements sst forth in this EDS; and that

all of the facts snd informsfion provided by the Undersigned in this EDS are true, complete snd correct. The Lindersigned agrees to

inform Ihs Chief Procurement Officer in voting if any of such statements, certiTicsfions, representations, fscfs or information

becomes or is found to be unius, incomplete or incorrect during the tenn of the Conlrad or County Pdvfiege,

BUslNEss NAME: Has xy / I 7~ ~/9

BUSINESS ADDRESS: 9 3~ A46 fan% t

>~O'~ 6,~~. (, par ~,BUSINESSTELEPHO E; M3~ 9 i 4 irx'AX NUMBERS& Eg ~g 9 5

CONTACTPERSON, J8dk +4' ru-cY Fl W

FEIN: 7 (x Yox' ~S Y *ILCORPORATE FILE NUMBER: X+/9 6 6~LIST THE FOLLOWING CORPORATE OFFICERS

SECRETARY.'WrF~tl 4 C T /6/~ ( pg TRIItIBURER: ~~rxud+ +udfiu'IQNATURE

DFAtsItEBIDENT: X~ I )he&'TTBSTi AJ~ 148~

"tF'J(CORPORATE SEC RETARYI

PRESIDENT Z QZ —.8 4d T VICE PRESIDENTi W<Qgvxx 'u pJ'~

Subscribed and sworn tc before me this

dayof Ax~4-,20 / I

"OFFICIAL SEALSTEVEN J. MILLER

NOTARY PUBLIC, STATE OF ILLINOIS

My Commission Expires 3/30/2018

My commission expires: 3+>4~3

itotary Public Signature Notary Seel .

If the oorporation is not registered in the State of filinois, a copy of the Certificate of Good Standing from ths statsof incorporation must be submitted with this Slgnetum Page.

In ths event that this Signature Page ls signed by any persons than the President and Secretary, agach either ecertified copy of the corporate by-hrws, resolution or other authodzaficn by the corporation, authorizing suchpersons to.sign the Signature Page on behalf of the corporation.

EDS-1Bc1.10.13

COOK COUNTY SIGNATURE PAGE

(SECTION 10)

ON BEHALF OF THE COUNTY OF COOK, A BODY POLlllC AND CORPORATE OF THE STATE OF ILLINOIS, THISCONTRACT IS HEREBY EXECUTED BY: .

COOK COUNTY CHIEF PROCUREMENT OFFICER

DATED AT CHICAGO, ILLINOIS THIS DAY OF .20

IN THE:CASE OF A BID'PROPOSAL THE COUNTY HEREBY ACCEPTS

.THE FOREGOING BID/PROPOSAL AS IDENTIFIED IN THE CONTRACT DOCUMENTS FOR CONTRACT NUMBER

ITEM(S), SECTION(S), PART(S):

TOTAL AMOUNT OF.CONTRACT: $(DOLLARS AND CENTS)

FUND CHARGEABLE,"

APPRDYEDASTOFORM: .

NA

ASSISTANT STATE'S ATTORNEY(Required on contracts over $1,000,000.00)

EDS-171.10.13

%CARD"WOODS-2 OP ID: KS

CERTIFICATE OF LIABILITY INSURANCE

~AI N E 847 205-1777 I IAIC. Noh 847-205-1 919~ADRREss eric 662000 ahoo.corn

INSURER($ 1 AFFORDING COVERAGE

MEURERA:United Fire 5 Casualty Com panV

msuRER s;The Hartford

INSURER C

INSURER D

INSURER E:INSURER F:

NAIC $

22357The Woodstock 5 Wallstreet CorAutomotive TechCenter437 Madison StreetOak Park, IL 50302

INSURED

COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIODIND/CATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT IVITH RESPECT TO WHICH THISCERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBEO HEREIN LR SUBJECT TO ALI. THE YERNIS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

INS R AAI SUSR POLICY EFF POLICY EXPLTR IYPECF INSURANCE INnn urvn POLICY NUMBER I IMMJDDIYYYYI JNMIDDJYYYYI LIMITS

THIS CERYIFICATE IS ISSUED AS A MATTER OF iNFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS.,CERTIFICATE DOES NOY AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIESBELOW. THIS CERTIFICATE OF INSURANCE DOEB NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED

: REPRESENTAllVE OR PRODUCER, AND THE CERTIFICATE HOLDER.

IMPORTANT: If the Certlf/cate holder is an ADDITIONAL INSURED, ths policy(les) must be endorsed, If SUBROGATION IS WAIVED, subject tcthe terms and conditions Qf the policy, certain pollclss msy require an endorsement, A statement on this certificate doss not confer rights to thece/tlocate holder in Beu of such endorsement(s).

PRODUCERNAME Eric Leader

Total Insurance Services, Inc. PHONE3175 Commerdal AvenueNorthbrock, IL 60062-1926Eric Leader

A MERCIAL GENERAL LIASILITY

CLAlalSMADE X OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER

POLICY ~ JEQ'I ~ Lcc~ PRO-

OTHER

AUTOMOSILELIASILRY

A X ANY Auro

60431024

60431024

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North Community Bank is listed as Mortgagee.435-449 Madison Street, Ohk Park IL Building Limit $970,QQQ654Q H,Roosevelt Road, Osk Perk rIL-Buildino —limit $837,6QO

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CANCELLATIOtf

NORCOMMSHOULD ANY OF THE ABOVE DESCRIBED POLICIEB BS CANCELLED BEFORETHE EXPIRATION DATE THEREOF, NOTICE INILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

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Oo 1988-2014 ACORD CORPORATION. AS rights reserved.The ACORD name end logo are registered marks of ACORD