Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf

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Attached to
Acquisition, Relocation and Related Real Estate Services
Solicitation number
RFQu-26-0091
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 involving Disadvantaged Business Enterprise (DBE) subcontractors. The form serves as a dual affidavit document requiring certification from both the prime contractor and the DBE firm confirming that full payment, including all retention amounts, has been made for materials and/or work performed on the project. The contractor must document the total amount paid to each DBE firm and declare under penalty of perjury that all statements are true and complete. Similarly, the DBE firm must certify that a contract was entered into with the prime contractor, that payments received are accurate and unchallenged, and that all statements are truthful. Supporting documentation for all payments is subject to audit and must be retained for a minimum of three years from the project acceptance date, with any instances of delayed or withheld payments requiring submission of supporting documentation to justify the prime contractor's position.

This certification form is directly applicable to the City of Phoenix's Request for Qualifications RFQu-26-0091 for acquisition, relocation, and related real estate services, which explicitly requires compliance with Disadvantaged Business Enterprise requirements under 49 CFR Part 26 for Federal Transit Administration (FTA)-assisted projects. Contractors awarded under this procurement must submit an initial DBE participation plan within 30 calendar days of contract award and annual updates thereafter, track and report all DBE participation monthly through the City's Certification and Compliance System, and maintain comprehensive documentation of all participating vendors. The certification form ensures accountability and compliance with federal DBE requirements by creating an official record of payment fulfillment to minority and disadvantaged business subcontractors participating in City of Phoenix 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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