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SVMM♦'sit <br /> ot, _+.0 DISPUTE DISCLOSURE <br /> �{�� �• City of Sunny Isles each <br /> •�:"ice • 18070 Corns.Avenue <br /> i e�•�. Sumry Isles Beach.FL 33160 <br /> o„um Telephone:(305)967-0606 Fax(305)9493113 <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 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 /> 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 V/ <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract daims, 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 /> eii&ft 394/1X436 (ne. 1105. 5. zt5 <br /> Frtn Date <br /> zed Signature f(DI,o Dtrw{or <br /> 9 Print`Or Type Name and Title <br /> D-CatiEn 28,2010 5 of 10 <br />