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O <br /> ® NNT„ <br /> (j �JJ <br /> ® oa^ DISPUTE DISCLOSURE <br /> ® V1 I\ S <br /> 1\\ �. City 1 70 Collins Isles Beach <br /> ® �� oT • 18070('. Avenue <br /> •stO <%` Sunny Isles Beach,FL 33160 <br /> ® o. 10 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 /> 0 Department of Professional Regulations or any other regulatory agency or professional associations within the last <br /> five (5) years? <br /> e <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 'OC <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 /> • <br /> ® YES NO xx 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 /> ft 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 /> Stockton Maintenance Group TS AJ <br /> ® Firm Date <br /> Doug Riordan Sole owner / President <br /> ® Authorized Signature Print or Type Name and Title <br /> • <br /> • DECEMBER 28.2010 6 of 10 <br />