Laserfiche WebLink
DISPUTE DISCLOSURE <br />City of Sunny lsles Beach <br />18070 Collin6 Avenue <br />Sunny lsles Beach, FL 33160 <br />Tel€phone: (305) 947{606 FaK (305) 049-3113 <br />DISPUTE DISCTOSURE FORM <br />Answer the following questions by placing a "X" after '.Yes,, or '.No". ff you answer ..yes', please <br />explain in the space provided, or on a separate sheet attached to this folm, <br />l9'1' 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 NOX <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 <br />- <br />NO X <br />19.3 Has your firm had against it or filed any requests for equltable adjustment, contract claims, Bid protesb, <br />or litigation in the past five (5) years that is related to the seruices 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 certiry that all statements made are true and agree and understand that any misstatement or <br />misrepresentation of falsification of facts shall be cause for fofeiture of rights for further cons'tderation of this Bid <br />for the City of Sunny Isles Beach. <br />L2/19t\6 <br />Date <br />Kara Hoffman Bavs President <br />Print or Type Name and Title <br />Firm <br />/----7Y--, <br />Authorized Slgnature <br />DECEMBER2S,20iO 6of10