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O�yJHNV,t`EI• <br /> DISPUTE DISCLOSURE <br /> 1 City of Sunny Isles Beach <br /> ,r o� 18070 Collins Avenue <br /> ®r • .o• Sunny Isles Beach,FL 33160 <br /> o, sum'�•+` Telephone:(305)947-0606 Fax:(305)949-3113 <br /> tip <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 /> kitty Department of Professional Regulations or any other regulatory agency or professional associations within the last <br /> five(5)years? <br /> tar YES NO <br /> per, 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 /> toy <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> 0 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 /> ice► <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 /> tatr 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 /> tip Firm . Date <br /> lirlir - 17 z>` =u o5 �,,t/ ,407 — We S 1 deYL"( <br /> ter Authorized Si• ature Print or Type Name and Title <br /> �4► <br /> star <br /> ,0 <br /> tar <br /> ice► <br /> DECEMBER 28.2010 6 of 8 <br /> .'. . • <br />