Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Flow Meters and Level Meters Supplemental
- Solicitation number
- IFB-27-0472
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Final Payment form administered by the Public Transit Department under the Disadvantaged Business Enterprise - Neutral (DBE-N) Program for the state of Arizona. The form serves as a bilateral certification mechanism requiring completion by both the prime contractor and small business subcontractor upon project completion. The contractor must certify that full payment, including all retention amounts, has been made to the cited small business firm for materials and/or work performed on the project contract. The form requires documentation of the total amount paid to the small business and must be supported by documentation retained for a minimum of three years from the project acceptance date. Both the contractor and small business firm must execute the certification under penalty of perjury in the second degree and applicable state or federal law, affirming the accuracy and completeness of payment information.
The document establishes audit requirements for payment documentation and addresses scenarios where payment disputes exist, requiring submission of supporting documentation if the small business was not paid in accordance with affidavits submitted by the successful bidder or if payments were delayed or withheld. The form does not contain pricing information, renewal options, or specific project details, as it functions as a post-completion compliance document rather than a solicitation or contract award notice. The DBE-N program designation indicates this procurement involves disadvantaged business enterprise considerations, though the specific set-aside percentage or contract value is not specified in this certification form.
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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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