Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Air-Fed Vertical Collating System
- Solicitation number
- IFB-27-0411
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Final Payment form for the Disadvantaged Business Enterprise - Neutral (DBE-N) Program administered by the Public Transit Department. The document serves as an official affidavit to be completed by prime contractors and small business subcontractors upon completion of work on Project 02_26-IFR PTD. The form requires the contractor to certify that full payment, including all retention amounts, has been made to small business firms engaged to perform materials and work on the project contract. The document establishes a formal record of the total compensation provided to each small business participant and must be signed under penalty of perjury by authorized agents of both the contractor and the small business firm.
The certification process requires retention of supporting payment documentation for a minimum of three years from the project acceptance date, with all records subject to audit. In cases where small businesses were not paid in accordance with affidavits submitted by the successful bidder, the bidder must submit all documentation supporting their position regarding any delayed or withheld payments. Both the contractor and small business must complete separate affidavits declaring under penalty of perjury in the second degree that all statements made are true and complete to the best of their knowledge. The form does not specify pricing terms or contract amounts but functions as a compliance and accountability mechanism within the DBE-N program framework.
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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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