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�q 11 T ,fir <br />DISPUTE DISCLOSURE <br />ui� z <br />City of Sunny Isles Beach <br />1 WM Collins Avenue <br />b �� ' o�` -0•` Sunny isles Beach, FL 33180 <br />Telephone: l=1 � —WO Fax ta05) 918.3113 <br />DISPUTE DISCLOSURE FORM <br />Answer the following qucstilwis by plaL;ny a "X- atter -Yes- yr ,Nu". It you answer "Yes", please <br />explain in the space provided, ur vn a separate sheet attached to this form. <br />19.1. Has your tiriu ur any at Its officers, rEqceivR a rwflmand of any nature or been suspended by the <br />Department of Prrtessiunal Regulations or any other regulatory agency or professional associations within the last <br />tive (5) years? <br />YES NO x <br />AZ Has yuui full, of any memBer or your hrm, Been aml-arm in detault, terminated or removed from a <br />contract or job related to the 5w -v;,.= your hrm provides In the regular course at Business within the Iasi five (5) <br />yea„? <br />YES NO <br />19.3. Has your firm Haid against it or filed any requests for equitable ai justment, contract daims, Iiia protests, <br />or litigation in the past five (5) yeaiz that is relatea to the wv-il.= your tine provides in the regular coarse of <br />Business? <br />YES NO It yes, state the nature of the request for equita6le 5djusunent, contract <br />claim, litigadw, or protest, and state a Erik description of the case, the outcome or status of the suit and the <br />monetary amounts ut extenf0ed contract time involved. <br />I hereby certify that all statements made are true and agrcv and cifl?IU Bad mat any misstatement or <br />misrepresentation of falsification of facts shall be cause rr rorreiture or rignts tur rui�ier consideration of this Bid <br />for the City of Sunny Isles Beach. <br />Cu=tie + Rogesu Design SEudia, Inc. Oo/C�/cvao <br />Fi <br />gnu <br />Aumuricea Siynature <br />Date <br />Aida M. Cu. -.tin - Prealdc..t <br />Print or Type Name and Tide <br />r, u.a—=29,20,0 iof r <br />