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0 «,$P Y .t,r+ . <br /> DISPUTE DISCLOSURE <br /> . City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> b '',•i 0,1,0?L` Sunny Isles Beach,FL 33160 <br /> of tv,. '� Telephone:(305)947-0606 Fax:(305)949-3113 <br /> I <br /> DISPUTE DISCLOSURE FORM <br /> IAnswer the following questions by pladng 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 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 /> 1 YES ' NO X <br /> 1 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 /> 1 years <br /> YES NO X <br /> I19.3. 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 /> Ibusiness? <br /> YES NO X If yes, state the nature of the request for equitable adjustment, contract <br /> 1 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 /> 1 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 /> I 1 0 Su Piss LLL /Z <br /> Firm -- Date <br /> 1 ! �qd,e I4JE,y AAA 4"/ vice- Aes.ra„ / of <br /> Authorized ' • C j� ' Print or Type Name and Title q �„e.— <br /> • <br /> I <br /> DECEMBER 28.2010 6 of 10 <br /> IProGrass RFP No. 12-10-03 128 <br />