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1 <br /> Appendix Ill — Proposal Forms (continued) <br /> .. ,, <br /> DISPUTE DISCLOSURE <br /> �'.:�± City of Sunny Isles Beach <br /> 8070 C W r¢Avenue <br /> Sunny Nes Beach,FL 33180 <br /> a..aTelephone.(305)947-0808 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 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 x <br /> 19.2. Has your firm, or any rrember of your fire, 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 x <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment,contract dairrs, Bid protests, <br /> or litigation in the past five (5) years that S related to the services your firm provides in the regular course of <br /> business? <br /> YES NO x 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 /> a for the Gty of Sunny Isles Beach. <br /> GLSC&Company,PLLC 12/28/2015 <br /> Firm///� 1.po- Date <br /> a -0 iVl) tmAck/ Pablo Berena,Partner <br /> Signaorre Pint or Type Name and Title <br /> 11 <br /> 1 <br /> 1 <br /> Oece,rea[9.2010 B of 7 <br /> I <br /> PROPOSAL <br /> GLSC&COMPANY, PLLC RFP # 15-12-01 <br /> CtiCertified public accountants <br />