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of ,•-`��ti o <br />_Y DISPUTE DISCLOSURE <br />V t 1I. <br />City of Sunny Isles Beach <br />•, E + 1 W70 CA&ns Avenue <br />'•t�'�• v o•rv�try Is#4 ftbM. FE 3-i 160 <br />' a. jun " TOWftW (947-06%Fax (305) %;%-0 110 <br />DISPUTE DISCLOSURE FORM <br />Answer tate following questions by placing a'X' after 'Yes' or 'No. if you answer `tree j please <br />explain in the space proyfil ed, or an a sparate sheet attached to this farm. <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 ftfessional 11"ulations or any other regulatory agency or protessierial associations within the last <br />frre (5) years? <br />YES.---- NO <br />19.8. Has your firm, or any membee of your firm, been declared in default, terminated or removed from a <br />contract or job related to the services your flan 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, cn ra€t clairns, Bid protests, <br />or litigation In the past five (5) yLam that is related to the smices your firm provides In the regular course of <br />husiness? <br />YE5 NO If yes, state the nature of the request for equitable adjustment, contract <br />claim, It+igation, or protest, and state a brief description of the crit?, the outcome or sQtus of the suit and the <br />monetary amounts of edmded contract time involved, <br />I hereby certify that; all statements made are true and agree and understand that any misstaternem or <br />misrepresentaWn of falsifocatlon of facts shall be cause for forfeiture of rights for farther consideration of this Bid <br />for the City of Sunny Isles Bch, <br />4KV, 2011 <br />7pany 8123116 <br />Date <br />Jason R. Wells <br />Print or Type Name and Title <br />G4f7 <br />