Laserfiche WebLink
D I SPUTE DISCLOSURE <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach , FL 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 t he 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 su sp ended by the <br />Depa rtment of Professional Regulations or any other regu latory agency or profe ssiona l associations within the last <br />five (5) years? <br />YES ___ _ X NO ___ _ <br />19.2. Has your firm , or an y mem ber of your fi r m , been declared in defau lt, terminated or removed from a <br />contract or job re lated to the services your firm prov ides in the regu lar course of business within the last fi ve (5) <br />ye ars? <br />YES ___ _ X NO ___ _ <br />19.3. Has your firm ha d against it or filed any requests for equi tab le adjustment, contract claims, Bid protests, <br />or litigation in the pas t fi ve (5 ) years that is related to the services you r firm prov ides in the regular course of <br />business? <br />YES NO X If yes, state the nature of the request for equitable adjustment, contr act <br />claim, litigation, or protest, and state a b rief description of the case, the outcome or status of the su it and t he <br />monetary amounts of extended contract time involved. <br />I he reby certify that all statements mad e are t rue and agree and understand that any misstatement or <br />misrepresentation of fa lsification of facts sha ll be cause for forfeiture of rights for further consideration of this Bid <br />f or the City of Sunny Isles Beach. <br />The Be taJo Group , Inc 7/14 /2026 <br />Firm Date <br />( Lu is A. Betalle l uz, Pri ncipal <br />Print or Type Name and T itle <br />DECEMBER 28, 2010 <br />83 The BetaJones Group/RFQ#26-07-01