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<br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />1 B070 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 />NO <br /> <br />X' <br /> <br />19.2. Has your firmr or any member of your firmr 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 />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 c1aimsr 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)(' If yes, state the nature of the request for equitable adjustmentr contract <br />c1aimr litigation, or protestr 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 />rJt.-U.ltD G,k)~Euct\o0 (1.-:Lc 5/3 \ ) Qo II <br />D~te I <br /> <br />-~rAeJ SIlVA / UAt0AC?eiL <br />Print or Type Name and Title <br /> <br /> <br />DECEMBER 28, 2010 <br /> <br />6 of 10 <br /> <br />~o <br /> <br />t\J4L-t \ 10 G,J,.)j-~uj- I~ <br /> <br />vr:v <br /> <br />II _"...,C j-' / <br />