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<br />r ' <br />i <br /> <br />! : <br /> <br />[ , <br />l <br /> <br />r ; <br />I <br />i ; <br /> <br />r ~ <br />I <br /> <br />l. <br /> <br />r: <br /> <br />[ 1 <br />l j <br /> <br />[ : <br />l : <br />I [: <br />[ : <br />[ ~ <br /> <br />r' <br />l J <br /> <br />L <br />L~ <br />l : <br />r: <br />L <br />L <br /> <br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947-0606 Fax: (305) 949-3113 <br /> <br />DISPUTE DISCLOSURE FORM <br /> <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 /> <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 /> <br />YES <br /> <br />x <br /> <br />NO <br /> <br />19.2. Has your firm. or any member of your firm, been declared in default. terminated qr removed from a <br />contract or job related to the services your finn provides in the regular course of business within the last five (5) <br />years? <br /> <br />YES <br /> <br />NO <br /> <br />x <br /> <br />19.3. Has your firm had against it or filed any requests for equitable adjustment, 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 /> <br />YES NO ,X 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 /> <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 /> <br /> <br />51/.{ /11 <br />, I <br />Date <br /> <br />4c1j/'~h~ LQ1Jillfl. jJ/L r. <br />Print or Type Name and Title I <br /> <br />DecalIlER 28, 2010 <br /> <br />60f7 <br /> <br />01 p <br />,] f 8 <br />