Certification_of_Final_Payment_PTD_02_2026_(DBE-N).pdf
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- Attached to
- Cooling Tower Water Treatment Services
- Solicitation number
- IFB 27-FMD-013
- Issued by
- Maricopa County, Phoenix City, Arizona
About this file
This document is a Certification of Final Payment form issued by the Public Transit Department under the Disadvantaged Business Enterprise - Neutral (DBE-N) Program. The form is designed to be completed by contractors and small business firms upon completion of work to certify that full payment, including all retention amounts, has been made to subcontractors. The certification requires the prime contractor to submit an affidavit confirming the total value of all payments made to the small business for materials and/or work performed on the project contract, along with the small business firm's name and corresponding payment amount. The small business must then provide a reciprocal affidavit confirming receipt of the stated payment amount and validating the accuracy of the contract terms between the parties.
Both the contractor and small business must declare under penalty of perjury in the second degree that all statements made on the certification are true and complete to the best of their knowledge, in accordance with applicable Federal and State laws concerning false statements. Supporting documentation for all payments is subject to audit and must be retained for a minimum of three years from the project acceptance date. In cases where the small business was not paid in accordance with affidavits submitted by the successful bidder, all documentation supporting positions regarding delayed or withheld payments must be submitted with the certification.
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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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