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S? "l�r<FI DISPUTE DISCLOSURE :: k< City of Sunny Isles Beach w - 130706omns Avenue Sunny Isles Bear , FL 33160 Teleonane, (305) 947-0606 Fax: (305) 949-3113 DISPUTE DISCLOSURE FORM Answer the following questions by placing a "X" after "Yes" or "No ". If you answer "Yes ", please explain in the space provided, or on a separate sheet attached to this form. 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5) years? YES NO X 19.2. Has your firm, or any member of your fine, 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 X 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or litigation in the past five (5) years that is related to the services your fine provides in the regular course of business? YES NO X 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 and 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 of Sunny Isles Beach. CES Consultants. Inc. Authorized Signature August 12, 2014 Date Rudy M. Ortiz. P . CGC PrPsid -nt/ M Print or Type Name and Title City of Sunny Isles Beach 73 �� Ccn;in wing ?r�fessicncf Services for = ngineerng RFQ Nc. 14 -07 -02 August 12. 201A 01'cL ^.n171 .IC