Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- HVAC Filter Maintenance and Repair
- Solicitation number
- 27-FMD-007
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to DBE Firms form used by the City of Phoenix Public Transit Department for the HVAC Filter Maintenance and Repair contract. The form serves as dual affidavits completed upon project completion, with one section for the contractor to certify that full payment (including all retention) has been made to Disadvantaged Business Enterprise (DBE) firms, and a second section for the DBE firm to certify receipt of payments for work or materials provided. The contractor affidavit requires documentation of the total amount paid to each DBE firm, while the DBE affidavit confirms the accuracy of payments received and that no payment disputes exist. Both sections require authorized signatures made under penalty of perjury in the second degree, with supporting documentation subject to audit and retention for a minimum of three years from the project acceptance date. The form includes provisions for contractors to submit documentation regarding any delayed or withheld payments if the DBE was not compensated in accordance with original affidavits.
This certification document is a compliance requirement for the three-year HVAC filter maintenance contract commencing September 1, 2026, which mandates DBE participation plans in accordance with 49 C.F.R. Part 26. Successful contractors must submit initial and annual DBE participation plans, maintain documentation of good faith efforts to engage DBE-certified suppliers through the Arizona UTRACS database, provide monthly reporting of DBE expenditures through the City's Certification and Compliance System, and designate a contract liaison for compliance reporting. The completion of this certification form demonstrates contractor adherence to federal civil rights regulations and the City of Phoenix's commitment to ensuring equitable payment distribution to certified disadvantaged business enterprises participating in municipal contracts.
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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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