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S <br /> ® ._4VµNY lS�E <br /> OF <br /> - DISPUTE DISCLOSURE <br /> V•t44": City of Sunny Isles Beach <br /> 99 F 18070 Collins Avenue <br /> s•� '•, .o" 05 Sunny Isles Beach,FL 33160 <br /> '7,OF sus"'` 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 2( <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 se ces your firm provides in the regular course of business within the last five (5) <br /> years? <br /> ® YES NO <br /> 0 <br /> ® Has your firm had again 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 protest, a 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 /> ® ► ` o n ►11 ��t Y1 13\9 ` 1'l <br /> ® Firm Ard Date <br /> iim0 h be\ kul <br /> Autho ized Slat e •� Print or Typ Name and Title <br /> S <br /> 40 <br /> • <br /> 6 of 7 <br /> • <br />