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<br />SECTION 19 <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 />19.1. 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 />19.2. 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 <br /> <br />19.3. 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 adjustment, <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 forfeiture of rights for further consideration of <br />this bid for the City of Sunny Isles Beach, Bid No. , Landscape Maintenance Services. <br /> <br />Firm <br /> <br />Date <br /> <br />Authorized Signature <br /> <br />Print or Type Name and Title <br /> <br />END OF SECTION <br /> <br />PAGE 94 OF 96 <br />BID No. <br />