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*•Of su"h <br />DISPUTE DISCLOSURE <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach,FL 33160 <br />Telephone:(305)947-0606 Fax:(305)949-3113 <br />DISPUTE DISCLOSURE FORM <br />Answer the following questions by placing a "X"after "Yes"or "No".If you answer "Yes",please <br />explain in the space provided,or on a separate sheet attached to this form. <br />19.1.Has your firm or any of its officers, received a reprimand of any nature or been suspended by the <br />Department of Professional Regulations or any other regulatory agency or professional associations within the last <br />five (5)years? <br />YES NO <br />19.2.Has your firm, or any member of your firm,been declared in default,terminated or removed from a <br />contract or job related to the services your firm provides in the regular course of business within the last five (5) <br />years? <br />YES NO '/ <br />19.3.Has your firm had against it or filed any requests for equitable adjustment,contract claims,Bid protests, <br />or litigation in the <br />business? <br />»past five (5)years that is related to the services your firm provides in the regular course of <br />if) <br />NO _^If yes,state the nature of the request for equitable adjustment,contract <br />claim, litigation, or protest,and state a brief description of the case,the outcome or status of the suit and the <br />monetary amounts of extended contract time involved. <br />I hereby certify that all statements made are true and agree and understand that any misstatement or <br />misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid <br />for the City of Sunny Isles Beach. <br />Crff.tmPSGn warder LLP jUki \°i <br />Firm .r,r»Date <br />ft <br />T» <br />**A 0 \v.V / <br />AuthorizecfSignature <br />DECEMBER 28,2010 <br />Joseph 6d(er,?aciY)or <br />Print or Type Name and Title <br />43