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4VNNY Isar. <br />0'k � <br />' DISPUTE DISCLOSURE <br />a. n <br />v S" x <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />yF 'a� F GOR�o �`r Sunny Isles Beach, FL 33160 <br />c,TY 0 St 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 X <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 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 righ for further consideration of this Bid <br />for the City of Sunny Isles Beach. <br />fi4D�s 6 �6 u.6 D l a6 /Z'ZCD <br />Firm Date <br />Authorized Signature <br />L 0/,/ HN-2- '79i:6 1D;4jr <br />Print or Type Name and Title <br />DECEMBER28,2010 6 of 8 <br />