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0 <br /> �SU$NY <br /> DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 Coffins Avenue <br /> 'E 'D�• a�° 5°� Sunny Isles Beach,FL 33160 <br /> Flo - <br /> ''o,sus''sO Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> 0 <br /> Answer the following questions by plating 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 <br /> 0 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 v <br /> ® Has your firm had against it or filed any requests for equitable adjustment, contract daims, 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 v/� <br /> If yes, state the nature of the request for equitable adjustment, contract <br /> ® daim, 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 /> ® Prestige Auto Transport Towing &Recovery, Inc. 11/30/2017 <br /> ® Firm Date <br /> Witt)(R._ f. 1CM 0.62.4 Nechelle Morales I President <br /> uthorized Signature Print or Type Name and Title <br /> 0 <br /> 0e <br /> e <br /> ® 6of7 <br /> :?ck Nutt TfeASOai totj-1t 4 ce-CC -% -r1 c. 1�i�'� RSP-1 -i 101 <br /> 1J <br />