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S <br /> ® e"H♦I! <br /> Q\ti �yy�JJ <br /> • <br /> �.\.f <br /> ® �-y� ,, DISPUTE DISCLOSURE <br /> ® V � City of Sunny Isles Beach <br /> o <br /> 0 18010 Co6fs Avenueo <br /> —� <br /> Sunny Isles Beata,FL 33160 <br /> o..,, telepacce:(305)947-0606 Far 1305)9493113 <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 <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 /> 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 /> ® Curtis + Rogers Design Studio, Inc. L} /2(, tit <br /> Firm <br /> a� �l�-�'o Date <br /> Aida M. Curtis, President <br /> Authorized Signature Print or Type Name and Title <br /> 41) <br /> S <br /> DECOMEA39.2ofa 6of7 <br /> ® _____ <br /> ® Curtis + Rogers Design Studio RFQ 12-04-02 • 52 <br />