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srYLke <br /> ® = DISPUTE DISCLOSURE <br /> `): City of Sunny Isles Beach <br /> -:1 -� 18070 Collins Avenue <br /> ® �'• ., <br /> v' 1)“ Sunny Isles Beach,FL 33160 <br /> t' 'o. ,vv 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 the space provided, or on a separate sheet attached to this form. <br /> O 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 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 /> 0 years? <br /> ® YES NO X <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 X 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 /> ® See Section 1 for Litigation Statement <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 /> • Calvin, Giordano & Associates, Inc. '7/ 6-0/01- <br /> • Firm Date <br /> • Dennis J. Giordano/ President <br /> • Authoriz-• - Print or Type Name and Title <br /> • <br /> • <br /> • <br /> 0 <br /> • <br /> • <br /> • <br /> • <br /> • <br /> DECEMBER 26,2010 6 of 7 <br />