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r F' • <br />DISPUTE DIS('[.()SLJRI; <br />City of Sunny Isles Beach <br />s'. I ROTC Lo4na A"n" <br />Sunny IslosSe A FL 33t6o <br />Tviopli (306j W -G606 Fax (365) 919-3tt:a <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 officeis, received a reprimand of any nature or been suspended by the <br />Department of Professional Regulations or any other regulatory agency or professional associations with -n 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 ad)ustment, contract claims, Bid protests, <br />or libgaton 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 "� If yes, state the nature of the request for equ table ad]ustment, 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 />Firm <br />0331(22 <br />Date <br />Authorized Signature print or Type Name and Title <br />6of8 <br />