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I FORMS + ATTACHMENTS© <br /> Professional Architecture Services for Government Center Lobby+Gateway Park <br /> ISVplN rig,�f� <br /> ,t :ID'' DISPUTE DISCLOSURE <br /> ```99 4.,,_J <br /> 'c o'-: City of Sunny Isles Beach <br /> ' 18070 Collins Avenue <br /> St i9"•F Boa' 'tSunny Isles Beach.FL 33160 <br /> C'''',OF SUS'''o Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> 1 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 ` `'„i. 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 /> i : -„`%., 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 /> I YES X 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. REFER TO SECTION G <br /> munderstand thatany hereby certify that all statements made are true and agree and 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 /> Song+Associates, Inc. January 8, 2018 <br /> IFirm , Date <br /> w Young Song, President <br /> Authorizes '.ignature ' Print or Type Name and Title <br /> i <br /> I <br /> 1 <br /> I <br /> I <br /> 6of7 <br /> SONG +ASSOCIATES 74 <br />