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111 <br /> ® ty NM1�-_�l5(FJ <br /> DISPUTE DISCLOSURE <br /> `.� City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> •r,o>r ;' Sunny Isles Beach,FL 33160 <br /> or,L ' 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 /> 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 /> 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 .f Sunny Isles Beach. <br /> • <br /> Perkins j4 Architects, Inc. January 9, 2018 <br /> Firm Date ,, <br /> '� • Lawrence-Kline, Managing Principal <br /> ® Auth>I !off signature Print or Type-Name and Title • <br /> 6ot7 <br /> Perkins-Will Qualifications for Architectural+Interior Design Services 127 <br />