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,5.�O`yVr1NY istej. <br /> �� DISPUTE DISCLOSURE <br /> " City of Sunny Isles Beach <br /> A ',Ds o f W� 18070 Collins Avenue <br /> %F '•f s o 9'‘ Q Sunny Isles Beach,FL 33160 <br /> Le o. ,�� 'N 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 7C <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 X <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 past five (5) years that is related to the services your firm provides in the regular course of <br /> business? <br /> YES NO )( <br /> Ifes, state the nature of the request for <br /> y eq 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 Suny Isles Beach. <br /> I r(4 e_ (A4 g <br /> I <br /> n Inl_L /19‘ <br /> Firat�ei-eie Se,-1-and.cm1(4" <br /> Authorized Signature Print or Type Name and Title <br /> DECEMBER 28,2010 <br />