Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Part-Time Television Engineering Services
- Solicitation number
- IFB-26-0141
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to Disadvantaged Business Enterprise (DBE) Firms form issued by the City of Phoenix Public Transit Department for use upon completion of contract work. The document serves as a dual affidavit requiring certification from both the prime contractor and the DBE firm that full payment, including all retention amounts, has been made for materials and/or work performed on a specified project. The form requires the contractor to document the total amount paid to the DBE firm and declare under penalty of perjury that payments have been made in accordance with all Federal and State laws. Similarly, the DBE firm must certify that it entered into a contract with the prime contractor, received the documented payments, and that such payments are accurate and unchallenged. Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date, and in cases of delayed or withheld payments, the contractor must submit documentation supporting its position regarding such discrepancies.
This certification form is a compliance document designed to ensure accountability in DBE participation on City of Phoenix contracts. The form includes exhibits referencing the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and this Certification of Final Payment. The document applies to the Part-Time Television Engineering Services contract (IFB-26-0141) for which the City is soliciting bids for a five-year agreement commencing May 16, 2026, with specific DBE and Small Business Enterprise (SBE) participation requirements under 49 CFR Part 26 regulations. Contractors must demonstrate good faith efforts to promote DBE and SBE firm participation and provide monthly reporting through the City's Certification and Compliance System, making this certification form an essential component of contract close-out procedures and regulatory compliance documentation.
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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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