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A <br /> ♦VN�N. I�j, <br /> 0 <br /> DISPUTEDISCLOSURE <br /> &&''d Ij <br /> I �h ;; City of Sunny Isles Beach <br /> O -' Sunny <br /> Collins Avenue <br /> '. ,yo ' ny Isles Beach,FL 33180 <br /> " " s.S.sr. Telephone:(305)947-0608 Fax:(305)949-3113 <br /> a DISPUTE DISCLOSURE FORM <br /> ® Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please <br /> 0 0 explain in the space provided, or on a separate sheet attached to this form. <br /> 0 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 /> • <br /> YES NO <br /> 19.2. Has your firm, or any member of your firm, been declared in default, terminated or removed from a <br /> O contract or job related to the services your firm provides in the regular course of business within the last five (5) <br /> O years? <br /> ® YES NO ✓ <br /> O <br /> ® 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, or <br /> 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 1� If yes, state the nature of the request for equitable adjustment, contract claim, <br /> litigation, or protest, and state a brief description of the case, the outcome or status of the suit and the monetary <br /> • amounts of extended contract time involved. <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 /> O for the City of Sunny Isles Beach. <br /> •i ^ <br /> Firm Date <br /> O C /�J_ C- -a_ X. it/.fig-„ - COB <br /> O Authorized Signature Print or Type Name and Title <br /> O <br /> i <br /> O <br /> O <br /> O <br /> O <br /> O <br /> O <br /> O <br /> O D¢o an 28,2010 6 of 7 <br /> O <br /> O <br />