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SVNIV.Y'_ S <br />A. <br />DISPUTE DISCLOSURE <br />City of Sunny Isles Beach <br />f�f ,DD''• s G a• ��p.Er 18070 Collins Avenue . <br />c, T a o ' Sunny Isles Beach, FL 33160 <br />'' n, SUrI as Telephone: (305) 947 -0606 Fax: (305) 949 -3113 <br />DISPUTE DISCLOSURE FORM <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 />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 />YES. NO..� <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 />YES NO \ <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 />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 />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 />AiLt IK �t ti �.� ' U I <br />rim Date <br />Authors Signature Print or Type Name and Title <br />DECEMBER 20, 2010 6 of 16 <br />