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SECTION 19 <br />DISPUTE DISCLOSURE FORM <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 />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 />YES NO <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 />YES NO y- <br />19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, <br />proposal protests, or litigation in the past five (5) years that is related to the services your firm provides <br />in the regular course of business? <br />YES NO X 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 />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 proposal for the City of Sunny Isles Beach, Proposal No. ID - l l - 0 1 Landscape <br />Maintenance Services. <br />`V Ak, 1.6 v (AESt [A APE l IJ gNGE I Z - 20 - 10 <br />Firm Date <br />6 0- tve'ta QRRNGH AJA, -A6E-rt <br />Authorized Signature Print or Type Name and Title <br />END OF SECTION <br />PAGE 103 OF 105 <br />PROPOSAL NO. <br />-6 7 1 <br />ValleyCrest Landscape Maint. <br />16400 NVV 127th Ave. <br />Miami, FL 33018 -1051 <br />