Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Hydrochloric and Citric Acid
- Solicitation number
- IFB-26-0146
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Full/Final Payment to DBE Firms form issued by the City of Phoenix Public Transit Department. The form is to be completed by the prime contractor and the Disadvantaged Business Enterprise (DBE) firm upon completion of work on a project contract.
The form consists of two affidavits. The contractor affidavit requires the authorized agent of the prime contractor to certify that full payment, including all retention, has been made to the named DBE firm for materials and/or work performed on the project contract. The contractor must identify the project number and name, the DBE firm name, and the total amount paid. Supporting documentation for payment must be retained for a minimum of three years from the project acceptance date. If the DBE was not paid in accordance with affidavits submitted by the successful bidder, all documentation supporting delayed or withheld payments must be submitted. The DBE firm affidavit requires the authorized agent of the DBE firm to certify that a contract was entered into with the prime contractor to perform work or provide materials on the project and that the total amount of payments received from the prime contract is accurate and unchallenged. Both affidavits are made under penalty of perjury in the second degree and applicable state or federal laws. Each affidavit requires the signature of an authorized agent, printed name and title, and date.
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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 .