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® S0$NY IS< <br /> • ��F+I <br /> ® = ;P DISPUTE DISCLOSURE <br /> ® ). City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> • ,l o.-` ° Sunny Isles Beach,FL 33160 <br /> ® • 'oI <br /> sus '+ 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 /> 9 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 /> ® years? <br /> ® YES NO X <br /> 0 <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 /> a 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. `t/(.y/(;__ <br /> ® Firm Date <br /> ® re' c5ci Shelley Eichner, AICP, Senior Vice President <br /> ® Authorized Signature Print or Type Name and Title <br /> 0 <br /> 0 <br /> DECEMBER 28,2010 6 of 7 <br />