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UT,NY Ds, <br /> / AFI <br />' <br /> V \n DISPUTE DISCLOSURE <br /> � , I <br /> City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> '. 1'•'LO's Yo' Sunny Isles Beach,FL 33160 <br /> 'o. su'. ' 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 /> 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 /> 1 <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 /> I hereby certify that all state - is m-se are true and .. --"and understand that any misstatement or <br /> misrepresentation of falsifi ti• of fa shall be cau - • orfeiture of rights for further consideration of this Bid <br /> for the City of S ny I -ach. <br /> Indiviiva1 jj 51) //Iv <br /> Firm � .� Date <br /> ����� Greg Batista, PE, CGC, CEM, LEED AP <br /> Authorized Sig - u Print or Type Name and Title <br /> DECEMB8 28,2010 6 of 7 <br />