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S0N7 if,E <br /> DISPUTE DISCLOSURE <br /> v _ <br /> =.. Z <br /> City of Sunny Isles Beach <br /> '' -.•o.;, 16070 Cot&ru Avenue <br /> s,' • r L o c Sunny Isles Beach,FL 33160 <br /> ''or svw' Teiept one:(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 /> 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 associations 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? �/ <br /> YES NO X <br /> 19.3. Has your firm had against it or filed any 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 /> business? <br /> YES NO X If yes, state the nature of the request for equitable adjustment, contract <br /> claim, 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 the City of Sunny Isles Beach. <br /> cey Inver ents, litA--&- ;b/a Elite Tent Company 8/23/16 <br /> liffolp Date <br /> Jason R. Wells <br /> thorized _na re Print or Type Name and Title <br /> Dsculast 28,2010 6o£7 <br />