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S,/HNY�,Z�• <br /> i DISPUTE DISCLOSURE <br /> 31 <br /> City of Sunny Isles Beach <br /> s„-. . Y' 18070 Collins Avenue <br /> '.��'-.,o�`O �` Sunny isles Beach,FL 33160 <br /> •o, ,ue 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, a • r - • brief description of the case, the outcome or status of the suit and the <br /> monetary amounts of ext-•ted contra time involved. <br /> ' I hereby cer•1r•. II statemen - made are t - •nd agree and understand that any misstatement or <br /> misreprese F• • fication o acts shal =- cause for forfeiture of rights for further consideration of this Bid <br /> p JI 9 <br /> for the City • kBeac <br /> Indi <br /> i ©e. S(//f2 <br /> FirmF,/, 70,714 <br /> - Date <br /> Greg Batista, PE, CGC, CEM, LEED AP <br /> A,thorized -��/'l• Print or Type Name and Title <br /> IDECEMBER 28,2010 6of7 <br />