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• • DISPUTE DISCLOSURE • `_ City of Sunny Isles Beach • �.. 18070 Collins Avenue • c�' no•so • 'r • a 4' Sunny Isles Beach,FL 33160 ® 'Of sun'� Telephone:(305)947-0606 Fax:(305)949-3113 - • • DISPUTE DISCLOSURE FORM • Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please • explain in the space provided, or on a separate sheet attached to this form. • 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the • Department of Professional Regulations or any other regulatory agency or professional associations within the last five (5)years? • • YES NO X • • 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a contract or job related to the services your firm provides in the regular course of business within the last five (5) • years? • YES NO x • • 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, • or litigation in the past five (5) years that is related to the services your firm provides in the regular course of business? • • YES NO X If yes, state the nature of the request for equitable adjustment, contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the • monetary amounts of extended contract time involved. • • I hereby certify that all statements made are true and agree and understand that any misstatement or • misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid for the City of Sunny Isles Beach. • ® Chen Moore and 's •ciates April 30, 2012 Firm Date • • • i Peter Moore, RE., LEED AP, President Authorized Sign. 1,11011r Print or Type Name and Title • • • • • O O CH N O0 RE RIONo.12-04-02 Continuing Professional Architectural&Engineering Services firms Only(CCNA) • Category:CivilEngineering 7-10 SASSOCATES 0