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NY 031 <br />GRy� <br />DISPUTE DISCLOSUR <br />City of Sunny isles Beach <br />18070 Collin Avenue <br />LOT., y`r <br />Sunny Isles 899M. F1. 33160 <br />c'ry or $us "` <br />Telephone: (306} 94741806 Fax: (306) 848.3113 <br />DISPUTE DISCLOSURE FORM <br />Answer the foilowinp questions by placing a "X° after "Yes" or "No ". If you answer "Yes"r 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 professlonai 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 ac'usbnenk 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 adjustrmen4 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 />Firm Dat�el _ <br />Aut Print or Type Name and Title <br />MORMeeR 28, 2010 W7 7 <br />