Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf

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