Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Heat Relief Supply Distribution Management
- Solicitation number
- RFP GGS-26-0100
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to Disadvantaged Business Enterprise (DBE) Firms document from the City of Phoenix Public Transit Department, designed for use upon completion of work on state and local contracts. The form functions as a dual affidavit requiring certification from both the prime contractor and the DBE firm, documenting that full payment—including all retention amounts—has been made for materials and work performed on the project. The contractor must complete the affidavit by providing the project name and number, the DBE firm name, and the total amount paid, while the DBE firm must verify receipt of payment and confirm that the amount is accurate and unchallenged. Both parties execute the document under penalty of perjury in the second degree and applicable state or federal laws, declaring the statements true and complete to the best of their knowledge.
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 instances where the DBE was not paid in accordance with affidavits submitted by the successful bidder, the contractor must submit all documentation supporting delayed or withheld payment positions. The form includes sections for the signature and printed name and title of authorized agents for both the contractor and DBE firm, with references to related exhibits including the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and DBE Certification of Final Payment. This certification mechanism ensures compliance with the City of Phoenix's disadvantaged business enterprise participation requirements and federal transportation program regulations.
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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 .