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SJNNY,SUFI <br /> O B <br /> _� DISPUTE DISCLOSURE <br /> • ?, <br /> •-. City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> 9 C P <br /> �s ''•F l CO's Oo' Sunny Isles Beach,FL 33160 <br /> OF suN '' 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 <br /> 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 <br /> 3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> 40 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 v 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 /> LL WE3135 EIsTERP(ZZs ) .. . . <br /> Firm Date = l I <br /> 9R vZO ✓ C 13� J2 R 6>=O607 <br /> Authorized Signature Print or Type Name and-Title` <br /> //I <br /> 6 of 10 <br />