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♦±atter s <br /> c _ 7,- .. DISPUTE DISCLOSURE <br /> .);� ;i• City of Sunny Isles Beach <br /> 113070 tomos Avenue <br /> :10` Sunny Isles Beads,FL 33160 <br /> • ". .0 Telephone:(305)947-0606 Fa.:(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? �I <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? X <br /> YES NO / ` <br /> 19.3. Has your firm had against it or filed any requests for equitable adjusirnent, 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 /> 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. y I l + <br /> 3-1 <br /> inn Allo, 7 — Date <br /> KIAcP to \-\Ocu2F - Real O&rc I e <br /> . rthoriz-• igna ails.ePrint or Type Name and Title <br /> Ora uaty 28.2010 6 of 10 <br /> kt <br /> 0 L 3 <br />