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SUNN•Is,F <br /> do_ ,.k\n DISPUTE DISCLOSURE <br /> I VI <br /> '�t1` ��i:/ City of Sunny Isles Beach <br /> '_ "� J 18070 Collins Avenue <br /> •, o%+'� Sunny Isles Beach,FL 33160 <br /> c. su• , Telephone:(305)947-0606 Fax:(305)949-3113 <br /> IDISPUTE DISCLOSURE FORM <br /> Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please <br /> Iexplain 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 /> 1 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 /> I <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> I 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 prot- , • . state a brief description of the case, the outcome or status of the suit and the <br /> monetary amounts • -xtended contract time involved. <br /> 1I hereby c: . -t all . ements made are true and •• - - and understand that any misstatement or <br /> misrepr- • sr 041 1 • alsifi . ion of facts shall be cau : •r forfeiture of rights for further consideration of this Bid <br /> I for the sles 'each. <br /> In,; £.91 sb'il/ <br /> Date <br /> I Firm ,/�-' Greg Batista, PE, CGC, CEM, LEED AP <br /> •uthoriz-•. 37,7 Print or Type Name and Title <br /> O <br /> I <br /> I <br /> UDecesBER 28,2010 6 of 7 <br />