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• • • swon'rhe • r DISPUTE DISCLOSURE • t �+_ City of Sunny Isles Beach ® •��t� 18070 Collins Avenue no.� o,. Sunny Isles Beach.FL 33160 ® t, "'or rya' Telephone:(305)947-0606 Fax:(305)949-3113 • • DISPUTE DISCLOSURE FORM • Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please • explain in the space provided, or on a separate sheet attached to this form. ® 19.1. Has your firm or any of its officers, received a reprimand of any nature or been suspended by the Department of Professional Regulations or any other regulatory agency or professional associations within the last • five (5) years? / • • YES NO V • • 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a ® contract or job related to the services your firm provides in the regular course of business within the last five (5) • years? YES NO V/ • • ® 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, -11/ or litigation in the past five (5) years that is related to the services your firm provides in the regular course of • business? • YES NO If yes, state the nature of the request for equitable adjustment, contract • claim, litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the • monetary amounts of extended contract time involved. • • I hereby certify that all statements made are true and agree and understand that any misstatement or • misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid • for the City of�Sunny �Isles Beach. 5y� po2C/2- • n • 559 5� /�7/'eciosas; ac. A/�2i1-- 7 2 /Z • Firm `= /Date ® se4C1t0�u41s iehteS /203tCb717— ® Autho Signature Print or Type Name and Title • • • • • • • • • 0 O DECEu11Fa20.2010 6 of 7 0• 0