Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
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- Attached to
- Employee Health Clinic Services
- Solicitation number
- RFP PS-26-0095
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Full/Final Payments to DBE Firms form issued by the City of Phoenix Public Transit Department for use upon completion of contractor work on public transit projects. The form serves as a dual affidavit document requiring certification from both the prime contractor and the Disadvantaged Business Enterprise (DBE) subcontractor that all payments, including retention amounts, have been made in full for materials and work performed. The certification must be completed and submitted by both parties upon project completion, with supporting documentation required to be retained for a minimum of three years from the project acceptance date.
The form requires the contractor to declare under penalty of perjury in the second degree that full payment has been made to the DBE firm, including the DBE firm name and total amount paid. The DBE firm must similarly certify that it has entered into a contract with the prime contractor and that the total payment amount received is accurate and unchallenged. Both the contractor's authorized agent and the DBE firm's authorized agent must sign and print their names and titles on the certification. In the event of delayed or withheld payments, the contractor must submit all supporting documentation explaining the payment status. This certification is a mandatory compliance requirement under Federal and State laws governing false statements and DBE participation on public projects.
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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 .