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. <br /> 1 f 5� T is, <br /> F <br /> DISPUTE DISCLOSURE <br /> '5 Z-. 1. <br /> � • City of Sunny Isles Beach <br /> • , ---.;---118070 Collins Avenue <br /> L <br /> ti, �0,•,,oF'o ." Sunny Isles Beach,FL 33160 <br /> f Of{1.10' 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 1. -Has your firm or any of its officers, received a reprimand of any natureor 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 /> • <br /> 1 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 /> • <br /> YES NO x • - <br /> I 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 /> business? <br /> x <br /> YES NO 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 /> 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 because for forfeiture of rights for further consideration of this Bid <br /> for the City of Sunny Isles Beach. <br /> 1 Tidal Basin Government Consulting,LLC • 5/8/2018 • <br /> Firm . Date <br /> IA - <br /> n . <br /> . Steven Glenn,Vice President <br /> Authorized Signature Print or Type Name and Title <br /> • <br /> 1 • <br /> 1 <br /> I . • <br /> I <br /> sotto • <br /> I. <br />