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• • t/SVNNT/I<E OA \EB ® c, \^ DISPUTE DISCLOSURE • City of Sunny Isles Beach • 18070 Collins Avenue • >;<-- • r iow Sunny Isles Beach,FL 33160 ® 'o. sow "i� 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 X. ® 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 • 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, • 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 A 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. p Et A( Rtit Date • C ?. r - B(144 W44pCICUT1 Pies-lc/c4 ® Authorized Signature Print or Type Name And Title • • • 0 • • 0 DECEVEER28.2010 6 of 10 •