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<br /> <br />DISPUTE DISCLOSURE <br /> <br />Cily of Sunny Isles Beach <br />18070 Collins Avenue <br />Sunny Isles Beach, FL 33160 <br />Telephone: (305) 947-0606 Fax: (30~) 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 />X <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 />y <br /> <br />19.3. Has your firm had against It or flied 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 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 /> <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 ~each. ;:2 <br /> <br />F~:r ~a/\ J-~.~#P~~4 Date' /O./?- <br />r:-/ --::-;. ''':;P---).-.)/' *t7<-{IVd1? <br />'""&)r'""'. '"C:Jq;~; ~ <br /> <br />D!CEMI!ER28.2010 <br /> <br />60f7 <br /> <br />'\"l ., .. , <br />,. II C! <br />,,) <br />