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`+VN /.5.4 <br /> Y f S<F <br /> � <br /> • 4 � DISPUTE DISCLOSURE <br /> • t ; is <br /> ,5 City of Sunny Isles Beach <br /> ..'4'.•,', y <br /> o 18070 Collins Avenue <br /> t.os .Y Sunny Isles Beach,FL 33160 <br /> ''0,s u+.,'`'' 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 "1 <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 /> 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 /> si®1iti®attb Flex:44 1 16 CeinzAraitetaTea It • t9 • t o <br /> Firm Date <br /> ' 1 e .Goal <br /> Authoriz Signature Print or Type Name and Title <br /> DECEMBER za,zoto 6 of 10 G <br />