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SUNNY,S< <br /> FJ <br /> it',:, <br /> DISPUTE DISCLOSURE <br /> • City of Sunny Isles Beach <br /> • <br /> :4:�'a➢�Y ts,w cP•� 18070 Collins Avenue <br /> `c,, -, R`�04` Sunny Isles Beach,FL 33160 <br /> °F s�" 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 /> 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___i __ <br /> 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 /> 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 If yes, state the nature of the request for equitable adjustment, contract <br /> claim, litigation, or protes , 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 /> 5 vnc-4- LA%4 ,,.r., Zz//7 <br /> Firm ate r <br /> �tf.. 4 CFO <br /> Au orized Signature Print or Type Name and Title <br /> 6 of 7 <br />