Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Print and Mail Election Materials
- Solicitation number
- RFP GGS-26-0079
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to DBE Firms form issued by the City of Phoenix Public Transit Department for use upon completion of work on state and local contracts. The document serves as a dual affidavit requiring completion by both the prime contractor and the Disadvantaged Business Enterprise (DBE) subcontractor to certify that full payment, including all retention amounts, has been made for materials and services provided. The form requires identification of the DBE firm, total amount paid, and signatures from authorized representatives of both the contractor and DBE firm declaring under penalty of perjury that all statements are true and complete. Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date, and any instances of delayed or withheld payments require submission of supporting documentation from the prime contractor explaining the circumstances.
This certification form is a critical compliance document specifically related to the City of Phoenix's Print and Mail Election Materials contract (RFP GGS-26-0079), which emphasizes significant DBE and small business participation requirements mandated by the United States Department of Transportation. Contractors awarded this five-year contract, with potential four one-year extensions, must submit an initial DBE/Small Business Participation Plan within 30 calendar days of award and provide monthly documentation of DBE engagement. The form ensures accountability in subcontractor payments and supports the city's enforcement of federal DBE participation mandates, with all documentation subject to audit to verify compliance with affidavits submitted during the bidding process.
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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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