Laserfiche WebLink
g <br />V NT„ <br />f <br />0 <br />DISPUTE DISCLOSURE <br />City of Sunny Isles Beach <br />c' a� <br />�; <br />18070 Collins Avenue <br />'<< • noR` +` <br />Sunny Isles Beach, FL 33160 <br />o <br />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 X <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 X <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 X NO 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. -See attached litigation history. <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 />Kimley -Horn and Associates, Inc. August 11, 2014 <br />Firm <br />Aut orized 'g a r <br />DeceMBEa28,2010 <br />RFQ 14 -07 -02 <br />Rimier -Horn <br />Date <br />Jay Jackson, P.E., Senior Vice President/Principal <br />Print or Type Name and Title <br />M <br />