Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Data Analytics Services State and local contract opportunity
- Solicitation number
- RFQu 2021-WAD-472-06
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Full/Final Payment form from the City of Phoenix Public Transit Department for a Disadvantaged Business Enterprise (DBE) payment verification process. The form requires completion by both the prime contractor and the DBE subcontractor upon project completion, serving as an official affidavit to confirm that full payment (including all retention) has been made to the DBE firm for materials and/or work performed on a specific project contract.
The document mandates that supporting documentation for the payment must be retained for a minimum of three years from the project acceptance date. Both the contractor and DBE firm must sign declarations under penalty of perjury, affirming the accuracy and completeness of the payment information. The form includes provisions for documenting the total amount paid to the DBE firm and requires signatures from authorized agents, with spaces for printed names, titles, and dates. This document appears to be part of the City of Phoenix's compliance and oversight mechanism for ensuring proper payment to DBE firms on public transit projects.
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Text version
By:
Date:
City of Phoenix
PUBLIC TRANSIT DEPARTMENT
CERTIFICATION OF FULL/FINAL PAYMENT TO DBE FIRMS
(TO BE COMPLETED BY THE CONTRACTOR & DBE FIRM UPON COMPLETION OF WORK)
CONTRACTOR AFFIDAVIT:
The undersigned, having contracted as the Contractor on Project _________________ (Project Number and Name) hereby certifies that full payment (including all retention) has been made to the DBE firm cited below. The total value of all payments made to the DBE firm for materials and/or work performed on this project contract is as follows:
DBE Firm:
Total Amount Paid:
This certification is made under Federal and State laws concerning false statement.
Supporting documentation for this payment is subject to audit and should be retained for a minimum of three (3) years from the project acceptance date. In the event the DBE was not paid in accordance with affidavits submitted by the Successful Bidder, all documentation supporting the Successful Bidder 's position with regards to delayed or withheld payment(s) should be submitted.
I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY
OTHER APPLICABLE STATE OR FEDERAL LAW, THE STATEMENTS MADE ON
THIS DOCUMENT ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE.
Signature of Authorized Agent for Contractor
Printed Name and Title
By:
Date:
DBE FIRM AFFIDAVIT:
(Name of DBE)
The undersigned DBE firm hereby certifies that a contract was entered into with the above named Contractor to perform work or provide materials on the project cited in this document. I further certify that the total amount of payments received as provided herein by the prime contract is accurate and unchallenged.
I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY
OTHER APPLICABLE STATE OF FEDERAL LAWS, THE STATEMENTS MADE ON
THIS DOCUMENT ARE TRUE AND COMPLETE TO THE BEST OF MY
KNOWLEDGE.
Signature of Authorized Agent for DBE Firm
Printed Name and Title
| Exhibit - Initial SBPP Plan |
| Exhibit - DBE Annual SBPP Plan |
| Exhibit - DBE Request for Substitution or Exemption |
| Exhibit - DBE Certification of Final Payment |
| CONTRACTOR AFFIDAVIT: |
| DBE Firm: |
| Total Amount Paid: |
| Printed Name and Title: |
| Text57: |
| Name of DBE: |
| Printed Name and Title_2: |
File details come from the government source that posted it. Updated .