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y0NN1„ ! <br /> —'h <br /> DISPUTE DISCLOSURE <br /> 6(- <br /> City of Sunny Isles Beach <br /> 18070 Carts Avenue <br /> Iv '. fot' .' sunny Isles Beach.FL 33160 <br /> ripa. s° Telephone:(305)967-0606 Far(305)969-3113 <br /> DISPUTE DISCLOSURE FORM <br /> Answer the following questions by pladng a "X" after "Yes" or "No". If you answer"Yes", please <br /> explain 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 ascnriations within the last <br /> five(5)years? <br /> YES NO X <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 /> years? v <br /> YES NO I <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract daims, 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 /> business? <br /> YES NO If yes, state the nature of the request for equitable adjustment, contract <br /> 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 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 tthe City of Sunny Isles Beach. <br /> h Cele b,nAa-n t c,et pre, In",_ ,Wa2,3`9-0/6 <br /> Finn <br /> tea/ <br /> � Dat <br /> / " Pres/ <br /> den� <br /> • l .rized Signature Print or Type Name and Title <br /> DECEmBER 28,2010 6 of 7 <br />