Attachment_-_Certification_of_Full_-_Final_Payments_to_DBE_Firms.pdf
PDF 106 KB Posted
- Attached to
- Evidence Bags
- Solicitation number
- IFB-26-0116
- 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 contracted work. The document serves as a dual affidavit requiring both the prime contractor and the Disadvantaged Business Enterprise (DBE) firm to certify that full payment, including all retention amounts, has been made for materials and work performed on a specific project contract. The form requires the contractor to document the total value of all payments made to the DBE firm and declare under penalty of perjury that statements made are true and complete. Similarly, the DBE firm must certify that a contract was entered into with the named contractor and that payment received is accurate and unchallenged. Supporting documentation for payments is subject to audit and must be retained for a minimum of three years from the project acceptance date.
The form is directly related to the City of Phoenix's Evidence Bags solicitation, a five-year contract with five option years commencing on or about May 1, 2026. This certification document functions as a compliance and documentation requirement for contractors awarded under the contract to demonstrate fulfillment of their DBE subcontracting obligations. In the event a DBE was not paid in accordance with affidavits submitted by the successful bidder, all documentation supporting the bidder's position regarding delayed or withheld payments must be submitted. The form includes exhibits for the Initial SBPP Plan, DBE Annual SBPP Plan, DBE Request for Substitution or Exemption, and DBE Certification of Final Payment.
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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 .