Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Print and Mail Election Materials
- Solicitation number
- RFP GGS-26-0079
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to 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 certification from both the prime contractor and the Disadvantaged Business Enterprise (DBE) subcontractor regarding payment fulfillment on a specified project. The contractor must certify that full payment, including all retention amounts, has been made to the DBE firm for materials and work performed, while the DBE firm must verify receipt of payment and confirm that the contracted work or materials were provided. Both parties execute the certification under penalty of perjury, declaring the accuracy and completeness of the payment information provided. 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 to justify the contractor's position.
This certification form is a mandatory compliance document for the City of Phoenix's Print and Mail Election Materials contract (RFP GGS-26-0079), which runs from April 1, 2026, through March 31, 2031, with four optional one-year renewal periods. The procurement emphasizes significant DBE and small business participation requirements mandated by the United States Department of Transportation. Contractors must submit an initial DBE/Small Business Participation Plan within 30 calendar days of contract award and provide monthly documentation of DBE engagement through phoenix.diversitycompliance.com. Any changes to DBE subcontractor involvement require submission of a Request for Substitution/Exemption form to ptdcompliance@phoenix.gov. The form is part of a comprehensive compliance framework that includes associated exhibits covering initial SBPP plans, DBE annual SBPP plans, and other substitution or exemption requests.
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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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