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DISPUTE DISCLOSURE <br /> ® City of Sunny Isles Beach <br /> • •. 18070 Caine Avenue <br /> �•�••,•rio• e•� Sunny Wes 6erh.FL 33160 <br /> e..v•� <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 assodations 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 NO x 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 /> I hereby certify that all statements made are true and agree and understand that any misstatement or <br /> misrepresentation of Isification of fads shall be cause for forfeiture of rights for further consideration of this Bid <br /> for MA ly of A lies Beau. <br /> Intel! Ss ! • -tion 5/10/2016 <br /> Firm Ill9 Date <br /> Dennis Peters,President and CEO <br /> Authorized Signature Print or Type Name and Title <br /> 411. <br /> DEMMER29,2010 6of7 <br />