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• <br /> L--CITY OF SUNNY ISLES BEACH <br /> I NT <br /> Sata RACTFO MS <br /> • ,VNNY IS(f <br /> • a' r'- f• <br /> ® = DISPUTE DISCLOSURE <br /> • City of Sunny Isles Beach <br /> • 18070 Collins Avenue <br /> -,ioa`O ,` Sunny Isles Beach,FL 33160 <br /> ® o, ,u • Telephone:(305)947-0606 Fax (305)949-3113 <br /> • <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 /> • <br /> 0 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 /> • <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 /> • <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 /> • <br /> • Keith and Schnars April 30,2012 <br /> Firm � Date <br /> • ;�C® Michael L.Davis,P.E.,Vice President <br /> Aut prized Signature Print or Type Name and Title <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> • <br /> j� ;•.KEITH and SCHISARS,P.A. <br /> •b RFQI 2-04-02 PAGE 43 "Jl� FLORID&$ LOCALFIRIN <br />