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• <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> 128 Contract Forms <br /> RFP—No.19-07-02 RFP—No.19-07-02 Contract Forms <br /> 129 <br /> • <br /> DISPUTE DISCLOSURE.. <br /> .7.. ..: A NoT,i1c;KICKBACK <br /> city°rum,win aeien <br /> .41:0,1•••a.,In 93110 <br /> lap W.A.. <br /> '.• ••••• gaurtraeat rr.'notriatini • <br /> •aanniran Oran,ft.lam <br /> DISPUTE Eggipplif FORM <br /> • ilINTI-I.:IKBACK AFFIDAVIT <br /> • ansWer tiw foliewIng quostiona try libeled a.r..afier'Yee;ot.-.7,No-:If trod answer 5.cri bye* <br /> explain In the sObereproshdeek ar on a spare.Shoot attached to this form-..• • <br /> , <br /> yEre rim,*any're Ls Odle*„retched a reprimand or err,ranee or boon sod:axed I*the STATE OF FLORIDA ) • <br /> Deparbrent Prontssend.hegutations or,any other Ined/d#21,agency co proLLOorol assodadaninithin the Iasi <br /> nnr Yebr? tOUhreY•OF ren:-0.04 <br /> ntS•: lid, L / <br /> I,the undersigned,hereby duly sworn and deposed say that no portion of this sum herein Bid <br /> -, - • inan <br /> if #005100 rile/ 01 Iwo be paid'to any emPloyees of the City of Sunny Isles Beads or Its elected offidals as a <br /> , noir sour boon easioreq In dermal.*energise or rembrod a <br /> .cOMmission,kickback,rewarder direcUy indlrectlY by me or any member of my Ann or <br /> *area or job rotated ari the metes year ton pro. .-rn ore legutor-congse tame.s ranin by Last Ow_(5) <br /> by an Officer of the corporation. <br /> • <br /> BY: 'Pita/ <br /> _ <br /> ILL Ku yibir Petit .roe&Pima iirftri a.;nieuosis for soiseie adjusbnint.contract cl.**,tad pretests.. <br /> N.(5)years that is related rottn seryiois your Ilrrn monde,in_the rota*or*or Tide: <br /> ' II roy stain the roston 0100 request 1 eadraron- <br /> Oath%•Bboahoti,or pretest and stabs desert:eon.or the. the optrorne or Pim or she kacano.n. The foregoing instrurnerit was:acknowledged before me this tn day of <br /> y amounts o(idended iontrea Ihno Insohrodo 4. 2° •O./ P6. rit oVre,r- •rname <br /> Irmo of outharityy for <br /> I hereby'certify Oat rstaienems;nide are tori and ridlte art Lroeistano apt any misstatement Cr [name of party.on behalf of whom instrument was <br /> parepreie.noition or fah/feat&Or,*la?oil*on**rorreytax at rights forAithe consideration-Or tho Elab &manna. <br /> •fer the Oty Or loony Islereekrt, L • ' <br /> • ?/ 6rr . <br /> AFP1*ikrrAFty <br /> \Ft63C147 —Au 6,L;D: <br /> Notary Public—State of Florida <br /> .Jo!: alchlthasw.OLO <br /> (-0,(\e, AucNC/ <br /> *no Ono.,alb <br /> in'sere reasearensne. XTYPe Commissioned Name <br /> • <br /> Personally Known OR Pnzduced Identification • <br /> Type Of Identification Produced t3 \c f.eis;12 <br /> • <br /> JACO•EII Cl/EATIVIL <br /> JA.00•1111 <br /> • <br /> • • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br />