Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Solicitation number
- RFP PS-26-0128
- 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 affidavit completed jointly by prime contractors and DBE subcontractors upon completion of work to certify that full payment, including all retention, has been made for materials and services provided on public transit projects. The form requires the contractor to identify the DBE firm, document the total amount paid, and declare under penalty of perjury that payments are accurate and complete. The DBE firm must similarly certify that a contract was executed with the prime contractor and that payment received matches the amount documented. Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date, and records are subject to audit by the City.
This certification form is applicable to the City of Phoenix's Occupational Medicine Staffing Services and Electronic Health Records Management contract (PS-26-0128), which includes Disadvantaged Business Enterprise requirements mandated under 49 CFR Part 26 for Federal Transit Administration-assisted projects. Contractors awarded this contract must develop and submit Small Business Participation Plans within 30 calendar days of award and annually thereafter, conduct good faith outreach to DBE-certified firms using the Arizona UTRACS database, and obtain City approval before implementing any DBE substitutions, exemptions, or reductions. The certification form ensures compliance with federal DBE participation requirements and creates a documented record of subcontractor payments for audit purposes.
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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 .