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�SVNNY rste <br /> i- -0� , DISPUTE DISCLOSURE <br /> �• City of Sunny Isles Beach <br /> �: 18070 Collins Avenue <br /> %e )•• F oa%o`4. Sunny Isles Beach,FL 33160 <br /> �"'"o, sus '''''3 <br /> so 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 <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 <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) ears that is related to the services your firm provides in the regular course of <br /> business? <br /> YES 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. <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 /> LC61(9$2-1 -1-1‘ 1-W-t_ II r / /7 <br /> Firm Date <br /> 0.... ._ <br /> iniqd4 (40V20 ital4tif <br /> Auth Ize SignaturePrint or Type Name and Title <br /> DECEMBER 28,2010 6 of/ <br />