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DISPUTE DISCLOSURE <br />1` �City of Sunny Isles Beach 16070 Collins Ave,ue <br />Sunny Isles Beach, F. 33160 <br />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 />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 V <br />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 v 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 />AA_ewd eannafW9Colne NA AX'SaCL elAAWk, <br />Firm Date <br />Z�,� 4�; 0'" ICJ Tuks i aQ ad PP -F-5 i L)rt — <br />Authorized Signature Print or Type NameAd Title <br />6 of 8 <br />