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OF SJµet'r(Fr <br /> � '� DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> 18070 CoPuss Avenue <br /> e'7,•noel c••• Sunny Isles Beach,FL 33160 <br /> a, ,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? X <br /> YES NO L \ <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 /X\ <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? \x/ <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 /> CO( iTU Ctt. _ ^� 19/I �l �. <br /> r ' yn y Dattt yyyy]7 /Oyy�lyr�Tt -e_SEO/� y� A <br /> At? orized Signe 1 re �- • v Prin or Type Na ndTitle J <br /> • <br /> OEC€I.EER 28.2010 6 of 10 <br /> Hellas Construction.Inc. RFP#12-10-03 P.103 <br />