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r. <br />DISPUTE DISCLOSURE <br />I' C�yofSurmy LrC-S ELeach <br />` Trlr_=•a134T,; #a7zA= ro, ryrl i <br />D LSPUTE DISCLOSURE rom <br />Answer the following quegtions by pb6ng a "Xw aft.,')res" or'Ne. if Xou answer "Yes-, plead <br />cxpla i n in the space pruvidK or on a separate sheet attached to this form. <br />19.1. Fia& vow flrrrL or ariv a iu otficcrg, rocerwtd -a rcprtr .nd of anY R, rxc or b&n rugm.w4ed by th* <br />DeWrret of Pmraw x-4 Re!�tltat Iorlg or grey Dlhcr mqi Luz wy • 4cncv or PmF +or+a] r-z%x,,3bM5 Wi hin die l3a <br />f�m ( 5) years'? <br />YES No — <br />19.2, HZ& your firm, OF any member of Your Fdmn% b00n c�tq0 in ��F7v:r, tatrni WrW ix rL-muvLd from j <br />coma:t or A rnlatnd in the se : im. your firm pr wkkd In #fes regUlal CDL9 c of hu3irW & wilts rk 11t- LLJ five: (5) <br />v7 <br />--- NG <br />19,3. Hm your rrm Ind arplrt!t it or fW zny+ re fir "ultable z-4:us-Men4 onnwNa dnwiSr M prOt,-SM, <br />Gr Uti�jun in ;he prW fwe (5) YEvj-; thai i5L r r!L3W la the %LxwklN- Vow ru-m pmvies in Rte regu!3F Cou r5,P_ rr <br />YB N0 "�•� if )rM VakL- the rwtuM of t hr! rv*►mt ry uqu ir., adiz merhr, cownba <br />dnn m, MlgAkm, or "est, and site hi bner def or,, pon of tt Case, a?re oummme or %taLu, 4f i he. Wi ,na vw <br />momtary my r-tx of eked contrwt time InvLolyed. <br />hereW catty that a.9 smun is made are wm and agree and ander that arrY rnissmn, ent cw <br />mk,mprewntaNnn of fakAiCwkn of Faits mag be cause far far otlrrc of rghts For further corK dffr5bc n of this 5d <br />far die Cty of Sur;Ry rsks 6 <br />LYzleo /,,A -q TSL, <br />film <br />Cr I I-N:bn 2011 <br />W/2(Pj-- - <br />Dat, <br />{w -h 0 60b - w"V- <br />Print art Type Na rye and Tole <br />