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 Payments to DBE Firms form issued by the City of Phoenix Public Transit Department for use upon completion of contract work involving Disadvantaged Business Enterprise (DBE) subcontractors. The form requires dual certification by both the prime contractor and the DBE firm to verify that full payment, including all retention amounts, has been made for materials and work performed on designated projects. The document serves as an affidavit under penalty of perjury in the second degree, with both parties required to provide the DBE firm name, total amount paid, authorized signatures, and printed names and titles. Supporting payment documentation must be retained for a minimum of three years from the project acceptance date, and the form explicitly addresses procedures for documenting delayed or withheld payments should they occur.
This certification requirement directly supports the City of Phoenix's DBE participation obligations under 49 C.F.R. Part 26 for the HVAC Filter Maintenance and Repair contract, a three-year initial term commencing September 1, 2026, with two optional one-year extensions covering approximately 120 municipal facilities. The form ensures compliance with federal civil rights regulations and the City's Small Business Participation Plan by providing documented evidence that DBE-certified suppliers have received full and timely compensation for their contract contributions. Contractors are required to designate a contract liaison responsible for compliance reporting and submit this certification upon project completion as a condition of satisfactory contract performance and payment.
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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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