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/)14HY is,,0 <br /> Coo Z DISPUTE DISCLOSURE <br /> •' '.� City of Sunny Isles Beach <br /> 4.-X19'• \O� e� 18070 Collins Avenue <br /> � Flog 0' Sunny Isles Beach,FL 33160 <br /> '`of SON''� 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 ]l <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> C 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 X 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 /> *1-`''°"".- NI• ZAc.— Cg,),ci 2_, <br /> Firm Date <br /> NM'Ar c _o'R 4` ,C / \/ <br /> Authorized Signa "- Print or Type Name and Title <br /> DECEMBER 28,2010 6 of 10 <br />