Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- HVAC Filter Maintenance and Repair
- Solicitation number
- 27-FMD-007
- 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. The document serves as a formal affidavit to be completed jointly by the prime contractor and Disadvantaged Business Enterprise (DBE) firm upon completion of work on a contracted project. The form requires the contractor to certify that full payment, including all retention amounts, has been made to the DBE firm, with the total value of payments for materials and/or work performed documented on the certification. The DBE firm must countersign the document to verify receipt of the stated payment amount and confirm that a contract was entered into with the prime contractor to perform the specified work or provide materials. Both parties declare under penalty of perjury that the statements made are true and complete to the best of their knowledge.
Supporting documentation for all payments is subject to audit and must be retained for a minimum of three years from the project acceptance date. In cases where the DBE was not paid in accordance with affidavits previously submitted by the successful bidder, all documentation supporting the bidder's position regarding delayed or withheld payments must be submitted with the certification. The form includes exhibits for the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and this Certification of Final Payment, establishing a comprehensive framework for tracking DBE participation and compliance throughout the contract lifecycle. This certification process ensures accountability and transparency in federal and state-mandated DBE program requirements for City of Phoenix contracts.
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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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