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® 1iT DISPUTE DISCLOSURE•e .o. sun' Telephone: B(305)947-0606 Far(305)949-3113 <br /> e DISPUTE DISCLOSURE FORM <br /> ®® Answer the following questions by placing a "X" after "Yes" or "No". If you answer "Yes", please <br /> 0 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 X <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 /> v 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 l 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 /> S naG 1 I ( C1 C / � 2-o l 2— <br /> • Firm I Date <br /> ® Authorized Signature Print or Type Name and Title • <br /> 0 <br /> S <br /> DECEMBER 26,2010 6 of 7 <br /> • <br />