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so NY isle <br /> s. <br /> DISPUTE DISCLOSURE <br /> _ j <br /> - City of Sunny Isles Beach <br /> ,r--- <br /> 18070 Collins Avenue <br /> ti, ,, ISPUTEr. Isles Beach,FL 33160 <br /> C."r o, ,u.0.� 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 X <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 X 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 /> The Goodyear Tire & Rubber Corn 09/05/2017 <br /> Firm Date <br /> —..M1/11,. /.-- <br /> --.---- Allan Alcerro Store Manager <br /> Authorized Sit-,..111"---- Print or Type Name and Title <br /> 6 of 7 <br />