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Vs"♦ it f <br /> Ol "'T�f <br /> ' _, DISPUTE DISCLOSURE <br /> i <br /> •. City of Sunny Isles Beach <br /> •• 18070 Carve Avenue <br /> a•;----0° <br /> •r v oo+` Sunny Isles Brach,FL 33160 <br /> 'o.s��' Telephone:(305)947-0606 Far.(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 acsoriations within the last <br /> five(5)years? <br /> • <br /> YES NO k7 <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 17- <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 ✓ 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 the City of Sunny Isles Beach. <br /> 11/e.- Cale bredion Sou,rte tyc /pi 14/ 9_o/40 <br /> Firm e� to <br /> _> 'Vice Pres' <br /> Authorized Signature Print or Type Name and Title <br /> oece.ffa 2e,2010 6o17 <br />