Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Laboratory-Grade Steam Sterilizer – Supply, Installation, Maintenance, Calibration, and Repair Services
- Solicitation number
- RFQ-27-0463
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This is a Certification of Final Payment form used by the Public Transit Department's Disadvantaged Business Enterprise - Neutral (DBE-N) Program in conjunction with a City of Phoenix procurement for laboratory-grade steam sterilizer supply, installation, maintenance, calibration, and repair services. The form is completed upon project work completion and serves as official documentation that the prime contractor has made full payment, including all retention amounts, to small business subcontractors. The related contract opportunity involves a five-year agreement with no extension options, with the commencement date occurring on or after City Council approval and ordinance effective date.
The certification form requires dual affidavits executed under penalty of perjury—one from the prime contractor and one from the small business firm—confirming the total amount paid for materials and work performed. Both parties must declare the accuracy and completeness of payment information, with supporting documentation subject to audit and retention requirements of a minimum of three years from project acceptance. The form specifically addresses scenarios where payment may have been delayed or withheld, requiring the successful bidder to submit documentation supporting their position regarding any such payment discrepancies. This form is integral to DBE-N compliance and payment verification procedures for the City of Phoenix's small business participation 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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