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<br />.J <br /> <br /> <br />DISPUTE DISCLOSURE <br /> <br />City of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny I sles 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 "Ves" or "No". If you answer "Ves", please <br />explain in the space provided, or on a .separate sheet attached to this fonn. <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 />';'l <br /> <br />19.2. Has your firm, or any member of your firm, been dedared 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 />)4 <br /> <br />19.3. Has your firm had against it or filed any requests for equitable adjustment, contract daims, 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 '-L If yes, state the nature of the request for equitable adjustment, contract <br />dalm, litigation, or pro~te 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 Oty of Sunny Isles Beach. <br /> <br />~ B<::=> G<<.~ LL- C-. <br /> <br /> <br />::oriZ~ Sl~ <br /> <br />o / ? (q <br /> <br />Date <br />\'01 ~"D1J~ <br />Print or Type Name and Title <br /> <br />~ <br /> <br />DECEloflER28.2010 <br /> <br />6 of 1 0 <br />