Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Full-Service Laundry and Rental Program
- Solicitation number
- RFP GGS-26-0384
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Final Payment form issued by the Public Transit Department's Disadvantaged Business Enterprise - Neutral (DBE-N) Program for use upon completion of contracted work. The form serves as a dual affidavit requiring both the prime contractor and subcontracted small business firm to certify that full payment, including all retention amounts, has been made for materials and work performed on a project contract. The contractor must document the total amount paid to the small business, while the small business must confirm receipt of payment and validate the accuracy of the payment amount without challenge. Both parties execute the document under penalty of perjury in the second degree and applicable state and federal 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 the small business was not paid in accordance with affidavits submitted by the successful bidder, the bidder must submit all documentation supporting its position regarding any delayed or withheld payments. This certification process ensures compliance with federal and state requirements governing small business payments and disadvantaged business enterprise programs in public transit contracts.
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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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