Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Evidence Bags
- Solicitation number
- IFB-26-0116
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to Disadvantaged Business Enterprise (DBE) Firms form issued by the City of Phoenix Public Transit Department for use upon completion of contracted work. The form serves as a dual affidavit document requiring completion by both the prime contractor and the DBE firm to certify that full payment, including all retention amounts, has been made for materials and/or work performed on a designated project. The contractor must document the total amount paid to each DBE firm, while the DBE firm must validate receipt of payment and confirm the accuracy of the stated amount. Both parties execute the document under penalty of perjury in the second degree and applicable state or federal laws. Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date, and any instances of delayed or withheld payments require submission of supporting documentation explaining the contractor's position.
This certification form is a mandatory compliance instrument applicable to City of Phoenix contracts subject to Federal Transit Administration assistance and 49 CFR Part 26 requirements governing DBE participation. The form functions as an audit trail mechanism, ensuring accountability in subcontractor payments and federal compliance with small business participation mandates. Contractors must complete the affidavit for each DBE firm engaged on the project, providing the DBE firm name, authorized agent signatures, printed names and titles, dates, and total compensation amounts. The documentation requirement ensures transparency in federal fund utilization and supports the City's demonstration of good faith efforts in promoting disadvantaged business enterprise participation across publicly funded 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: |
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