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<br />SECTION 20 <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 />20.1. 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 />x <br /> <br />20.2. 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 NO X <br /> <br />20.3. 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 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 /> <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. () 1r - LJ b - () ~ . Janitorial <br />Services Maintenance <br /> <br />~'I <br />. D U 1: ~ Z_ <br />Firm <br />~~ 1/40/kP' <br />Authoriz gnature <br /> <br />~/6 - 2..3- o?? <br />Date <br /> <br />(rJJrf'vi f/arfi4r7J'7 -~~I <br />Print or ype Name an Itle <br /> <br />END OF SECTION <br /> <br />PAGE 76 Of 78 <br />