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suN ,„, <br /> DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> Sunny Isles Beach.FL 33160 <br /> o. (vs 4 Telephone:(305)947-0606 Fax:(305)949-3113 <br /> 0 <br /> o DISPUTE DISCLOSURE FORM <br /> 8 Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please <br /> O explain in the space provided, or on a separate sheet attached to this form. <br /> O 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 <br /> 0 <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 <br /> 0 <br /> 0 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 /> 0 <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 /> O'Leary Richards Design Associates, Inc. May 1, 2012 <br /> F/irf5 t` Date <br /> , I)/� Jai 1 Kathryn O'Leary Richards, President <br /> • Authorized Sd:ture Print or Type Name and Title <br /> 0 <br /> 0 <br /> 0 <br /> 0 <br /> s <br /> • <br /> ® DECEMBER 28.2010 6 of 7 <br />