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4.F SVNNis,, <br /> DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> Sunny Isles Beach.FL 33160 <br /> os sus' Telephone:(305)947-0606 Fax(305)949-3113 <br /> • <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 <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 /> • <br /> years? <br /> YES <br /> NO <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 /> 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 /> Firm <br /> Date <br /> --� <br /> eir v1 ,-7X-0& <br /> Authoriz-a S'- ature Print or Type Name and Title <br /> • <br /> 6of7 <br /> DECEMBER 28.2010 <br />