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<br />SECTION 20 <br />DISPUTE DISCLOSURE FORM <br /> <br />Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", <br />please explain in the space provided, or on a separate sheet attached to this form. <br /> <br />20.1. Has you 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 <br />the last fIVe (5) years? <br /> <br />YES <br /> <br />NO )( <br /> <br />20.2. Has your firm, or any member of your firm, been declared in default, terminated or removed <br />from a contract or job related to the services your firm proVides in the regular course of business within <br />the last five (5) years? <br /> <br />YES <br /> <br />NO K <br /> <br />20.3, Has your firm had against it or filed any requests for equitable adjustment, contract claims, bid <br />protests, or litigation in the past five (5) years that is related to the services your firm provides in the <br />regular course of business? <br /> <br />YES NO ~ If yes, state the nature of the request for equitable adjusbnent, <br />contract claim, litigation, or protest, and state a brief description of the case, the outcome or status of <br />the suit and the monetary amounts of extended contract time involved. <br /> <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 fo eiture of rights for further consideration of <br />this bid for the City of Sunny Isles Beach, Bid No. 0 - () - 0 Janitorial <br />Services 7a\ntenance <br /> <br />sb",k+c,,,,, t{"-I"J'Ht~y.(.C~ ~""r' P ~ /1- 0 i <br />~~_____ ~ Date ~. R:a j <br /> <br />Authorized ignature <br /> <br /> <br />END OF SECTION <br /> <br />PAGE 76 OF 78 <br />