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i 1 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "!4" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 1. Has your firm or any of its officers, received a reprimand or any nature or been suspended by the Department of Professional Regulations o: any other regulatory agency or professional associations within the last five (5) years? YES NO X 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO 3, Has your firm had against it or riled any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES X NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit arid the monetary amounts of extended contract time involved, I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City or Sunny isles Beach. DRC EErlergency Services, LLCA 1 - Firm Hate Kristy Fuentes W/Secretaryffreasurer Authorised Sig nat'uti Print or Type Name and Title fi of 10 120 gaNMY +�{4J f DISPU-t'L' DISCLOSURE Cily oI Sunny Istes Beach ^'aT 1irOM Callins Avanue r;� , r l &nuiy ifts 1910.00, FL 53150 � Q+ • Q, yWo ,* TelephafP.. 303}947•0646iex: (305)949.3113 i 1 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "!4" after "Yes" or "No". If you answer "Yes", please explain in the space provided, or on a separate sheet attached to this form. 1. Has your firm or any of its officers, received a reprimand or any nature or been suspended by the Department of Professional Regulations o: any other regulatory agency or professional associations within the last five (5) years? YES NO X 2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) years? YES NO 3, Has your firm had against it or riled any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? YES X NO If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit arid the monetary amounts of extended contract time involved, I hereby certify that all statements made are true and agree and understand that any misstatement or misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City or Sunny isles Beach. DRC EErlergency Services, LLCA 1 - Firm Hate Kristy Fuentes W/Secretaryffreasurer Authorised Sig nat'uti Print or Type Name and Title fi of 10 120