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<br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, R. 33160 <br />Telephotle: (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 II separate sheet attached to this fo~. <br /> <br />19.1. Has your firm or any of Its officers, received a reprimand of any nat\.ire or been suspended by the <br />Department of Professional Regulations or any other regulatory agency or professional assodations within the last <br />five (5) years? <br /> <br />YES <br /> <br />NO <br /> <br />v <br /> <br />19.2. Has your firm, or any member of your firm, been declared in default,. ~ermlnated or removed from a <br />contract or job related to the services your firm provides In the regular course of ~usiness within the last five (5) <br />~~ ~ . <br /> <br />YES NO V <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 / If yes, state the nature of the request fori equitable adjustment, contract <br />daim, 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 /> <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 theOty of Sunny Isles Beach. ; <br /> <br />, ~ f.&c... .t)~//u;// <br />Date . <br /> <br /><l~ S' C/h'~/J ~/a"",.,- <br />Print or Type Name and l1tle <br /> <br />60f7 <br /> <br />Oecf"""'R 28, 2010 <br />