Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Parks and Recreation Event-Related Services
- Solicitation number
- PKS-RFQu-26-0119
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Full/Final Payments to DBE Firms form issued by the City of Phoenix Public Transit Department, designed to be completed by contractors and Disadvantaged Business Enterprise (DBE) firms upon project completion. The form serves as an official affidavit confirming that full payment, including all retention funds, has been made to DBE subcontractors for materials and work performed on a project contract. The certification requires contractors to document the total value of all payments made to the DBE firm and is made under penalty of perjury in the second degree and applicable state and federal laws. Supporting documentation for payments must be retained for a minimum of three years from the project acceptance date, and all documentation regarding delayed or withheld payments must be submitted if the DBE was not paid in accordance with the Successful Bidder's affidavits.
The form includes parallel affidavit sections for both the prime contractor and the DBE firm, each requiring signatures from authorized agents with printed names and titles. The DBE firm certifies that a contract was entered into with the named contractor and that payment received is accurate and unchallenged. This certification form is referenced as an exhibit within the City of Phoenix's broader procurement process and serves as a compliance mechanism to ensure that DBE participation goals are met and that subcontractors receive timely and complete payment, with all records subject to audit by the City.
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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 .