Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
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- Attached to
- Forcible Entry Props and Related Accessories
- Solicitation number
- IFB-27-0393
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Final Payment form used by the Public Transit Department under the Disadvantaged Business Enterprise - Neutral (DBE-N) Program to document completion of work and payment to small business firms on contracted projects. The form serves as a dual affidavit requiring certification from both the prime contractor and the subcontracted small business firm that all work has been completed and full payment, including any retention amounts, has been made. The contractor must document the total value of all payments made to the small business for materials and services performed, with supporting documentation required to be retained for a minimum of three years from the project acceptance date.
Both the contractor and small business must execute the document under penalty of perjury in the second degree and applicable state and federal laws, certifying the accuracy and completeness of payment information. In cases where payment disputes exist, the contractor must submit all documentation supporting delayed or withheld payments. This certification form functions as a required compliance document to verify that small business subcontractors receive timely and complete payment on public transit projects in accordance with the DBE-N program requirements.
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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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