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f . . , <br /> C <br /> VNNYir/s4.ti DISPUTE DISCLOSURE <br /> City of Sunny Isles Beach <br /> �• 18070 Collins Avenues� ?.,c -a�°'•,°'' Sunny�o Isles Beach,FL 33160 • <br /> c'''''o,.'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 /> 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 <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 <br /> 19.3. 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 /> YES NO \k 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 /> 0' 114/e/1 0 8 ( 'I4'2020 <br /> Fir Date <br /> 14)i 0 ,44.oti , i'-L I C.c0 <br /> Authorized Sign.ur• Print or Type Name and Title <br /> DECEMBER 28,2010 <br />