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<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 "xn after "Yesn 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 />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 />years? . <br /> <br />YES <br /> <br />NO <br /> <br />~ <br /> <br />19.3. Has your firm had against it or filed any req.uests 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 K. If yes, state the nature of the request for equitable adjustment, contract <br />claIm, litigation, or protest, and $t~ a brief description of the case, the outtome or statUs of the suit and the <br />monetary amounts of extended contract time Involved. <br /> <br />l hereby certify that all statements <br />misrepresentation of falsification of fa <br />for the CIty of Sunny Islef ch. <br /> <br />ade are true and agree and understand that any misstatement or <br />shall be cause for forfeiture of rights for further consideration of this Bid <br /> <br /> <br />nntt.-1 i c,,,J 5- ;) )- 2 0 II <br />Date J <br />J-<:CA're0 \--loovet - T reS4"cr,L-Tt <br />Print or Type Name and TItle <br /> <br />60f7 <br /> <br />DECEMllER2B.2010 <br />