Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Chiller and Boiler System Maintenance
- Solicitation number
- IFB FY27-086-03
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Final Payment form issued by the Public Transit Department under the Disadvantaged Business Enterprise - Neutral (DBE-N) Program, designed to be completed by prime contractors and small business subcontractors upon completion of work on a project contract. The form serves as an official affidavit confirming that full payment, including all retention funds, has been made to small business firms for materials and work performed on the project. The contractor must document the small business firm name and total amount paid, while the small business must verify receipt of payment and confirm the accuracy of the payment amount. Both parties execute the certification under penalty of perjury in the second degree and applicable federal and state laws.
Supporting documentation for all payments must be retained for a minimum of three years from the project acceptance date and is subject to audit. In cases where payment disputes arise, including delayed or withheld payments, the successful bidder must submit comprehensive documentation supporting their position. This certification requirement applies to the related City of Phoenix chiller and boiler system maintenance contract, which is a five-year agreement with no extension options, commencing upon City Council approval and final signature by the City Clerk's department.
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Text version
Disadvantaged Business Enterprise - Neutral (DBE-N) Program AGENCY: Public Transit Department
02_26-IFR PTD
CERTIFICATION OF FULL/FINAL PAYMENT TO SMALL BUSINESS FIRMS
(TO BE COMPLETED BY THE CONTRACTOR & SMALL BUSINESS UPON COMPLETION OF WORK)
CONTRACTOR AFFIDAVIT:
The undersigned, having contracted as the Contractor on Project NUMBER and Name hereby certifies that full payment (including all retention) has been made to the Small Business cited below. The total value of all payments made to the Small Business for materials and/or work performed on this project contract is as follows:
Small Business 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 Small Business 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.
By:
Authorized Agent for Contractor (Print Name and Title)
Date:
SMALL BUSINESS AFFIDAVIT: Insert Name of Small Business
The undersigned Small Business 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.
By: ______________________________ _____________________________________ Authorized Agent for Small Business (Print Name and Title)
Date:
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