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CITY OF SUNNY iSLES BEACH '® <br /> ;E':dr SECTION SIX CONTRACT'FORMS r r"'r <br /> • <br /> • <br /> SV$NY ,flf <br /> DISPUTE DISCLOSURE <br /> V tl + <br /> City of Sunny Isles Beach <br /> y1En'f'` Y 18070 Collins Avenue <br /> ie 7•f Loa' Sunny Isles Beach,FL 33160 <br /> o, suo''° Telephone:(305)947-0606 Fax (305)949-3113 411 <br /> DISPUTE DISCLOSURE FORM co <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 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 /> 11a <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 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 /> , <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 /> Keith and Schnars April 30,2012 <br /> Firm Date <br /> V, 0` Michael L.Davis,P.E.,Vice President <br /> Auth rized Signature Print or Type Name and Title <br /> 0 <br /> 000 <br /> 0 <br /> KEITH and SCHNARS,RA. 0 <br /> Fww°as PjiS',LOGLFIRM PAGE 68 RFOJ 2-04-02 <br />