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1100 <br /> 4110 <br /> 111, O <br /> � �Sup1Nv' EJ� <br /> V , �= DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> Sf/y9) F`0`N .,�` Sunny Isles Beach,FL 33160 <br /> o, sum Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> it <br /> Answer the following questions by placing a "X" "Yes"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 /> +fir Department of Professional Regulations or any other regulatory agency or professional associations within the last <br /> five(5) years? <br /> it YES NO <br /> Air <br /> e, 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 /> lir► 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 past five (5) years that is related to the services your firm provides in the regular course of <br /> business? <br /> 411, <br /> YES 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 /> r 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 /> +1r for the City of Sunny Isles Beach. <br /> too A(4.11/1e2.- s ilt(4)//7 _�11 _ - 3 ._ 17- 2,d8 <br /> +lam► Firmin - 111, <br /> Date <br /> /45 AZA7,4,-- -We S de rt. <br /> Authorized Si. ature Print or Type Name and Title <br /> Oar' <br /> +ii>rr <br /> IOW <br /> DECEMBER 28,2010 6 of 8 <br />