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 Disadvantaged Business Enterprise (DBE) Firms form from the City of Phoenix Public Transit Department. The document serves as an affidavit process requiring both prime contractors and DBE firms to certify completion of payment obligations upon project completion. The form includes two separate sections: a Contractor Affidavit in which the prime contractor certifies that full payment, including all retention, has been made to the identified DBE firm, and a DBE Firm Affidavit in which the subcontractor certifies receipt of contracted payments and acknowledges the accuracy of payment amounts. Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date. Both the contractor and DBE firm representatives must sign the certification under penalty of perjury in the second degree and any other applicable state or federal law.
The form functions as a compliance mechanism for the City of Phoenix's DBE participation requirements mandated under 49 C.F.R. Part 26. All payments made to DBE firms for materials and work performed must be documented and certified upon project completion. In the event of delayed or withheld payments, contractors must submit supporting documentation explaining their position regarding payment discrepancies. This certification requirement applies to the HVAC Filter Maintenance and Repair contract for municipal facilities, where successful bidders are obligated to maintain comprehensive DBE participation plans and provide monthly reporting of all DBE and small business expenditures through the City's Certification and Compliance System portal.
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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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