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F <br />1 y 5 �. -ry ertF <br />=I, DI-SPUTE DISCLOSURE <br />V � S <br />City of Sunny Isles Beach <br />1074 Collins Awnue <br />%�,'' • rte�', v4. Svnny Islas Ben -IF, Fi 52160 <br />�' =a .o� "� Telephorq (SO�j sb7-06flfi Fax {305j 9:$ 3113 <br />DISPUTE DISCLOSURE FORM <br />Answer the following questions by placing a "X" after "Yes" or "No If you ans►iper `iYes•. f please <br />explain in the space provided, or on a separate -sheet attached to this form. <br />1. -Has your firm or any of its officers, received a reprimand of ary nature or been suspended by the <br />Department of Professional Regulations or any other regulatory agency at professional associations within the last <br />five (5) years? t <br />YES NO _ X <br />2. Has your firm, or any member of your frrrr>, been declared in default, terminated or removed frorn ? <br />contract cr 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 />3. ' Has your firm had against it or filed any requasts for equitable adjustment, contract claims, Bid protests, <br />Dr litigation in the past five (5) years that is related io the services your firm provides in the regular course of <br />business? <br />x <br />YES NO If yes, state the nature of the request for equitable adjustment, contract <br />claim-, litigation, or protest, and skate a brief description of the rase, the outcome or status of the strlt and the <br />monetary amount$ of extended contract time involved. <br />i hereby certify that all statements made are true and agree and understand that any rnlsstatement or <br />misrepreseritation of falsification of Fad shall be.cau5e For Forfeiture of rights for further considermon of this Bid <br />for the City of Sunny Isles Beath. <br />[ic!al Basin Gmmmmem Consulting, LLC 5E8� 49A <br />Firm Datt; <br />5tewen Glenn, %r-w Pm uide,nt <br />Authorized Signature Print or Type Name arEd Title <br />I <br />I <br />I <br />6 fif 16 <br />�I <br />