Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Employee Health Clinic Services
- Solicitation number
- RFP PS-26-0095
- 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. The document serves as an official certification mechanism to verify that contractors have made complete and final payments to DBE firms upon project completion. The form requires dual affidavits—one from the prime contractor and one from the DBE firm—certifying the accuracy of payments made for materials and work performed on a specific project. Both the contractor and DBE firm must declare under penalty of perjury in the second degree that all statements made are true and complete. Supporting documentation for all payments is subject to audit and must be retained for a minimum of three years from the project acceptance date. In cases where delayed or withheld payments occur, contractors must submit documentation supporting their position regarding such payment discrepancies.
The certification form is designed to ensure compliance with Federal and State laws governing false statements and is part of the City of Phoenix's broader Small Business Participation Plan (SBPP) and DBE compliance framework, as referenced through exhibits for the Initial SBPP Plan, DBE Annual SBPP Plan, Request for Substitution or Exemption, and DBE Certification of Final Payment. The document requires completion of specific fields including the DBE firm name, total amount paid, authorized agent signatures and printed names with titles from both the contractor and DBE firm, and project identification information. This form is integral to the City's oversight of DBE utilization and payment practices on public works projects subject to 49 CFR Part 26 requirements.
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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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