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Mp DISPUTE DISCLOSURE <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />os suN �� Telephone: (305) 947-0606 Fax (305) 949-8113 <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 />19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by tine <br />Department of Professional Regulations or any other regulatory agency or professional as within the last <br />five (5) years? <br />YES NO <br />19.2. 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 />19.3. 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 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 Peach. <br />DEGElaM 28, 2010 <br />o("/.z(0f20-2,9 <br />bate <br />\1041A C081t as. pne-S.1boa <br />Print or Type. Name and Title <br />