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<br />..., <br /> <br />. <br /> <br />,.., <br /> <br />. <br /> <br />M <br /> <br />. <br /> <br />,., <br />. <br /> <br />r"'1 <br /> <br />. <br /> <br />,.., <br /> <br />. <br /> <br />..., <br /> <br />. <br /> <br />M <br /> <br />. <br /> <br />f""1 <br /> <br />. <br /> <br />...., <br /> <br />. <br /> <br />.., <br /> <br />. <br /> <br />n <br /> <br />. <br /> <br />..., <br /> <br />. <br /> <br />,..., <br /> <br />. <br /> <br />r-o <br /> <br />. <br /> <br />...., <br /> <br />. <br /> <br />M <br /> <br />. <br /> <br />,.., <br /> <br />. <br /> <br />- <br /> <br />- <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 NO <br /> <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 /> <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 /> <br />I herebv certify that all statements made are true and agree and understand that any misstatement or <br />misreoresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid <br /> <br />~~~\0dn&o Co~h \ 'D <br /> <br />LGs-\-k U~;~ C~-(2- <br /> <br />\[ t C9~ ~ R~J-t& / Q U&Q t.tur <br />/vtCQi{ I ':f ( '20 IJ <br /> <br />DECEMBER 28, 2010 <br /> <br />6 of 10 <br />