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di, of <br /> • <br /> DISPUTE DISCLOSURE <br /> GI V <br /> ® �.\ City of Sunny Beach <br /> o.'` <br /> 18070 Coals Avenue <br /> •.-co•' onny Isles <br /> Sunny Isles Beach,FL 33160 <br /> 'o. ,v.. • Telephone.(305)947-0606 Fa<(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 X <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 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 X 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 OW of Sunny Isles Beach. <br /> Sorts Turf On- Inc, December 11, 2012 <br /> F Date <br /> � � William Gillen. Vic- President <br /> Authorized • !rare- Print or Type Name and Title <br /> DECEMBER 23,20 10 6of 10 <br />