Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
PDF 142 KB Posted
- Attached to
- Employee Wellness Platform
- Solicitation number
- RFP PS-27-0485
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This file is a Certification of Final Payment form from the Public Transit Department under the Disadvantaged Business Enterprise - Neutral (DBE-N) Program. The form serves as a certification document to be completed jointly by the prime contractor and small business subcontractor upon completion of work on a project contract. The document requires the contractor to certify that full payment, including all retention amounts, has been made to the identified small business firm, with the total value of all payments for materials and/or work performed documented in the form.
The form establishes specific documentation and compliance requirements, mandating that supporting documentation for payments be retained for a minimum of three years from the project acceptance date. Both the contractor and small business must execute the certification under penalty of perjury in the second degree and applicable state or federal law, with authorized agents required to provide printed names, titles, and signatures. In instances where payment delays or withholding occurs, the contractor must submit all documentation supporting its position regarding such payment discrepancies. This certification mechanism ensures accountability and transparency in subcontractor payment practices under 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:
File details come from the government source that posted it. Updated .