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SNNY;N <br /> ``7, DISPUTE DISCLOSURE <br /> ✓• �, I S <br /> ® 11111 City of Sunny Isles Beach <br /> „..,... j:' 18070 Collins Avenue <br /> e l`tto,"' 0.'' Sunny Isles Beach,FL 33160 <br /> o. 51.04'''4 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 anyof 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 V <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 V/ <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 /> 411 business? <br /> YES NO v Ifes state the nature y to e 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 . les Beach. <br /> .L, los d. a act .xr JB2 III ab/ 7 <br /> Firm Agy Date <br /> avAifill,48.... 64 aily ,...51.442.4)10, , evasIbea-r- <br /> Autho .-d fP re Print or Type Name and Title . <br /> 0 <br /> Ofil°11. iitp,A5 <br /> s o17 <br /> 6'a iN' 17-1(-01 <br />