Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Solicitation number
- RFP 27-SWDD-006
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payments to Disadvantaged Business Enterprise (DBE) Firms form issued by the City of Phoenix Public Transit Department, designed to document completed payments to DBE subcontractors upon project completion. The form requires dual certification by both the prime contractor and the DBE firm, with the contractor affirming that full payment, including all retention amounts, has been made to the cited DBE firm for materials and work performed on the project. The document serves as an official record of the total value of payments made to each DBE firm and must be completed and executed by authorized agents of both parties, with supporting documentation retained for a minimum of three years from the project acceptance date. Both the contractor affidavit and DBE firm affidavit sections require signed declarations under penalty of perjury in the second degree, affirming the accuracy and completeness of payment information provided.
The form functions as a compliance and audit mechanism within the City of Phoenix's DBE participation program, ensuring accountability in subcontractor payments and supporting the City's commitment to promoting disadvantaged business enterprise engagement in municipal contracts. All supporting documentation for payments is subject to audit, and any instances of delayed or withheld payments require submission of supporting documentation from the prime contractor explaining the circumstances. The certification process includes reference to related exhibits, including the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and this DBE Certification of Final Payment, which collectively comprise the City's Small Business Participation Program documentation requirements for contract execution.
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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: |
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