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uate+' <br /> ..`;Y0 DISPUTE DISCLOSURE <br /> -:.'•� ' "� City of Sunny Isles Beach <br /> 18070 Collins Avenue <br /> .rises ; <br /> 9 ;,FLp1° :.4: Sunny Isles Beach,FL 33160 <br /> r <br /> > ` . (305)947-0606 Fax:(305)949-3113 <br /> oF,`s�N Telephone: <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 /> • <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 \A 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 /> I 114/&& 8H4-7,oW <br /> Fir fiDate <br /> ( cJ <br /> Authorized Sign. urs• Print or Type Name and Title <br /> DECEMBER28,2010 <br />