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so$NY 154E <br /> - yn DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> •.9Dv,A e, a 4`'P a 18070 Collins Avenue <br /> sf- '•F i 0 0 Sunny Isles Beach,FL 33160 <br /> ''o, sus '` 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 /> 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 X <br /> 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 X <br /> Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> Aft or litigation in the past five (5) years that is related to the services your firm provides in the regular course of <br /> 1. <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 /> a.1 6-14T C1A o,Le �v,f), 06" 3'31 ) \ '— <br /> Firm �y Date <br /> .. 0-0 6 1R-.0 \-t U A__\--EL( <br /> . Authorized Signature Print or Type Name and Title <br /> fa <br /> 6of7 <br />