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I . <br /> NN r 11GS� F <br /> op/ --- -.\. <br /> �( <br /> . • DISPUTE DISCLOSURE <br /> • - t,. <br /> City of Sunny Isles Beach <br /> ', 18070 Collins Avenue <br /> :'�.'•r t o"‘o . Sunny Isles Beach,FL 33160 <br /> Cpl•or 5V•• '''''' <br /> V•• 'MO 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 /> 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 /> Ifive(5) years? <br /> YES NO ✓ <br /> 1 <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 /> 1 years? <br /> YES NO ✓ <br /> 19.3. Has you r firm h ad aga in st it or filed an y 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 /> 1 business? <br /> YES NO ✓ If yes, state the nature of the request for equitable adjustment, contract <br /> I daim, 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 /> I 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 /> 1 Moore Stephens Lovelace, P.A. 12/29/15 <br /> Firm Date <br /> I t6:N---, )-+ 1�� Daniel J. O'Keefe, Shareholder <br /> Authorized Signature L Print or Type Name and Title <br /> I <br /> I <br /> I <br /> DECEUBER 29,2010 6o,7 <br />