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ONNY Is< S <br />DISPUTE DISCLOSURE <br />t. City of Sunny Isles Beach <br />18070 Collins Avenue <br />LonsOP�e Sunny Isles Beach, FL 33160 <br />oF .�N "`�o} Telephone: (305) 947-0606 Fax: (305) 949-3113 <br />DISPUTE DISCLOSURE FORM <br />Answer <br />the following questions <br />by <br />placing a "X" <br />after "Yes" or <br />. If you answer "Yes", <br />please <br />explain <br />in the space provided, or <br />on <br />a separate <br />sheet attached to <br />this form. <br />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 <br />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 />3. Has your firm had against it or f led 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 l� 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 rights for further consideration of this Bid <br />for the City of Sunny Isles Beach. <br />Authorized <br />2 <br />" Date 1 <br />�rir►t demo 6/ - / <br />Print or Type Name and Title t <br />6of12 <br />