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0 <br /> DISPUTE DISCLOSURE <br /> O <br /> ® ` City of Sunny Isles Beach <br /> _ , •-. 18070 Collins Avenue <br /> --'std''•:rio"xoo f Sunny Isles Beach,FL 33160 <br /> c;oisdx?� Telephone:(305)947-0606 Fax:(305)949-3113 <br /> DISPUTE DISCLOSURE FORM <br /> O <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 /> O 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 /> o years? <br /> ® YES NO _ X <br /> O <br /> 19.3. Has your firm had against it or filed any requests for equitable adjustment, contract claims, Bid protests, <br /> O or litigation in the past five (5) years that is related to the services your firm provides in the regular course of <br /> O business? <br /> (see attached list)* <br /> • YES X NO If yes, state the nature of the request for equitable adjustment, contract <br /> O 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 /> O <br /> I hereby certify that all statements made are true and agree and understand that any misstatement or <br /> O misrepresentation of falsification of facts shall be cause for forfeiture of rights for further consideration of this Bid <br /> 0 for the City of Sunny Isles Beach. <br /> o Kimley-Hom and Associates, Inc. April 30, 2012 <br /> errO Fir ) Date <br /> ® fu Jerry Ingram, P.E.,Senior Vice President/Principal Associate <br /> ® Au ized Signat re Print or Type Name and Title <br /> 'As required in RFQ No. 12-04-02, Kimley-Horn and Associates, Inc.has reviewed the proposed contract terms and conditions language as <br /> • written and objects to the language in total since it applies to Contractor Services and not Professional Services as are being requested in the <br /> O RFQ.In a discussion with the City Attorney in 2011,he indicated it would be appropriate to object to this language in total and that,if selected, <br /> ® Kimley-Hom would be provided the opportunity to provide the Professional Services using appropriate contract terms.Therefore,if selected <br /> again,we reserve the right to negotiate for a professional services contract similar in wording to the contracts that have been mutually <br /> acceptable to all parties in the past. <br /> O <br /> O <br /> O <br /> O DECEMBER 28,2010 6 of 7 <br /> O <br />