Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Heat Relief Supply Distribution Management
- Solicitation number
- RFP GGS-26-0100
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payment to Disadvantaged Business Enterprise (DBE) Firms document issued by the City of Phoenix Public Transit Department. The form serves as a dual-affidavit mechanism requiring completion by both the contractor and the DBE firm upon project completion. The document establishes a formal process for certifying that full payment, including all retention amounts, has been made to DBE firms for materials and work performed on City of Phoenix contracts. The certification requires the contractor to identify the specific DBE firm and document the total amount paid, while the DBE firm must verify receipt of payments and confirm that the amount is accurate and unchallenged. Both parties declare under penalty of perjury in the second degree that their statements are true and complete.
Supporting documentation for payments must be retained for a minimum of three years from the project acceptance date and is subject to audit. The form includes provisions for contractors to submit documentation explaining any delayed or withheld payments if the DBE was not paid in accordance with affidavits previously submitted by the successful bidder. This certification requirement directly relates to the City of Phoenix's Heat Relief Supply Distribution Management contract (RFP GGS-26-0100), which mandates DBE and small business participation under the United States Department of Transportation's DBE program. Contractors must demonstrate good faith efforts in promoting DBE participation and provide monthly documentation of such participation through the City's Certification and Compliance System throughout the contract term.
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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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