CERTIFICATION OF FULL/FINAL PAYMENT TO DBE FIRMS

(TO BE COMPLETED BY THE CONTRACTOR & DBE FIRM 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 DBE firm cited below. The total value of all payments made to the DBE firm for materials and/or work performed on this project contract is as follows:

DBE 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 DBE 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:

DBE FIRM AFFIDAVIT: Name of DBE

The undersigned DBE firm 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 DBE Firm (Print Name and Title)

Date:

Exhibit B: Small Business Participation Forms

REVISED 7/2024

REQUEST FOR SUBSTITUTION/EXEMPTION

THIS FORM MUST BE SUBMITTED TO THE CITY OF PHOENIX, PUBLIC TRANSIT DEPARTMENT COMPLIANCE SECTION, FOR APPROVAL PRIOR TO MAKING ANY CHANGES TO THE PROPOSED STATEMENT OF DBE UTILIZATION OR CONTRACTOR’S MONTHLY STATEMENT OF DBE UTILIZATION FORM. NO DBE SHALL BE SUBSTITUTED OR TERMINATED, NOR SHALL THEIR SCOPE OF WORK BE REDUCED OR PROPOSED AMOUNT

CHANGED WITHOUT THE APPROVAL OF THE CONTRACT COMPLIANCE SECTION.

Prime Contractor:

Contract Number:

Project Number and Description:

Affected DBE Subcontractor(s):

Scope of Work to be Performed by Affected DBE Subcontractors(s):

1. I am the duly authorized representative of the above listed Prime Contractor and am authorized to request this exemption on behalf of the Prime Contractor.

2. I hereby request that an exemption be granted to the above mentioned Prime Contractor to (circle those that apply);

A. release a proposed DBE subcontractor

B. change the scope of work to be performed by an DBE subcontractor

C. substitute a DBE subcontractor

D. reduce the amount originally proposed for a

DBE subcontractor

3. I have summarized the Prime Contractor's request for an exemption and the good faith efforts required in finding additional DBE participation on the above-mentioned contract as follows: (Attach additional pages and supporting documentation as necessary.)

Authorized Signature: ________________________________________________ Date: ___________________ Prime Contractor's Representative

Name and Title: _____________________________________________________ Phone: __________________

FOR CONTRACT COMPLIANCE USE ONLY

Request Approved: __________ (YES) __________ (NO) Revised DBE Goal: ________ %

REVISED DBE UTILIZATION _____________________________________________________________________________________

Contract Compliance Specialist: __________________________________________________ Date: ____________________________

City of Phoenix

PUBLIC TRANSIT DEPARTMENT

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

PTD Disadvantaged Business Enterprise/Small Business Participation Plan Initial Plan Submission

*Due 30 calendar days after Award*

Contract No. ____________

The above-referenced contract is subject to the Public Transit Department’s Disadvantaged Business Enterprise (DBE) program requirements issued by the United States Department of Transportation (USDOT) in 49 CFR part 26. ______________________________ will track and report all the participation that occurs in any procurement, joint ventures, goods/services, and other arrangements involving a DBE or a Small Business. the company submits its Small Business Participation Plan (SBPP) and agrees to comply with the small business outreach requirements to use good faith and reasonable efforts to promote and foster the participation of Small Businesses and DBE firms on Federal Transit Administration (FTA) assisted projects.

I. DBE Participation Commitment

The above company is committed to using good faith efforts by engaging and soliciting the services of Small Businesses and DBE firms as new and existing needs for services arise. The company will actively attempt to contract small, disadvantaged businesses, in addition to encouraging the businesses to pursue DBE certification.

Below is an outline of our good-faith plan to demonstrate our efforts to foster small, disadvantaged businesses and DBE participation in FTA-assisted projects:

1. Contact the PTD DBE Compliance Specialist for assistance and guidance regarding this plan.

2. Identify opportunities for DBE-certified suppliers to provide goods and services.

3. Identify DBE-certified firms in the AZ (UTRACS) database and engage in proactive outreach efforts to inform the certified firms of opportunities.

4. Send letters to DBE suppliers encouraging them to contact our company with proposals regarding providing goods and services and to keep a log of all letters, contacts, responses, and non-responses.

5. Encourage other suppliers who may be eligible to apply for DBE certification.

6. Make the best reasonable efforts to obtain and utilize the services of DBE businesses.

https://utracs.azdot.gov/

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

II. Company Responsibilities:

_____________ understands the requirements to comply with Public Transit Department Small Business Participation Plan and 49 CFR Part 26. The company will track and report all DBE, and/or small business participation that occurs on transit related projects as a result of a contract, procurements, purchase orders, subleases, JV, goods/services or other arrangements involving sub-tier participation. This documentation will be entered monthly into the City’s reporting program “Certification and Compliance System” at phoenix.diversitycompliance.com.

III. List of Goods and Services

The company has identified this list as potential categories of goods and services that can be purchased from small businesses and DBE certified suppliers on transit related projects:

1. ________________________________

2. ________________________________

3. ________________________________

4. ________________________________

5. ________________________________

6. ________________________________

7. ________________________________

8. ________________________________

9. ________________________________

10. ________________________________

Other commitments:

https://phoenix.diversitycompliance.com/

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

IV. DBE Firms Currently in Use

Listed below are the DBE firms and small businesses that are currently participating with the company as subcontractors, joint venture partners, suppliers of goods and services, and other business relationships:

1. ________________________________

2. ________________________________

3. ________________________________

4. ________________________________

5. ________________________________

6. ________________________________

7. ________________________________

8. ________________________________

V. Future Opportunities* for DBE Participation

The company working on a transit-related project will use the City of Phoenix and Federal databases as a starting point to locate and engage potential opportunities of DBE suppliers. Potential opportunities for DBE participation include:

*Please list scopes of work of vendor and/or goods and services area(s)

3. ________________________________

4. ________________________________

5. ________________________________

(add more lines as needed)

This list will be assessed at the next submission of the annual SBPP.

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

VI. The chart below summarizes all the expenditures made to Certified DBEs and small businesses during the past year.

Company Name Point of contact Email DBE or SBE Total Amount Paid During the Past Year* (MM-DD-YYYY to MM-DD-YYYY) *Does not apply to the first year of SBPP

VII. Annual DBE/Small Business Participation Plan Submission

The contractor shall complete and submit an updated SBPP, including any associated supporting documentation requested by the Agency or Subrecipient, on an annual basis from the contract start.

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

VIII. Contract Liason

____________________ will be responsible for submitting the Small Business Participation Plan on a yearly basis and other required reports by the contracting agency.

a. Contact Information:

Name: _________________________________________________________

Phone: _____________________ Cell:________________________

E-mail: _________________________________________________________

Address: ________________________________________________________

Date: ________________________

**Please submit all supporting documentation with your SBPP.**

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

PTD Disadvantaged Business Enterprise/Small Business Participation Plan Annual Plan Submission

*Due annually on the anniversary date of contract execution*

Contract No. ____________

The above-referenced contract is subject to the Public Transit Department’s Disadvantaged Business Enterprise (DBE) program requirements issued by the United States Department of Transportation (USDOT) in 49 CFR part 26. ______________________________ will track and report all the participation that occurs in any procurement, joint ventures, goods/services, and other arrangements involving a DBE or a Small Business. the company submits its Small Business Participation Plan (SBPP) and agrees to comply with the small business outreach requirements to use good faith and reasonable efforts to promote and foster the participation of Small Businesses and DBE firms on Federal Transit Administration (FTA) assisted projects.

I. DBE Participation Commitment

The above company is committed to using good faith efforts by engaging and soliciting the services of Small Businesses and DBE firms as new and existing needs for services arise. The company will actively attempt to contract small, disadvantaged businesses, in addition to encouraging the businesses to pursue DBE certification.

Below is an outline of our good-faith plan to demonstrate our efforts to foster small, disadvantaged businesses and DBE participation in FTA-assisted projects:

1. Contact the PTD DBE Compliance Specialist for assistance and guidance regarding this plan.

2. Identify opportunities for DBE-certified suppliers to provide goods and services.

3. Identify DBE-certified firms in the AZ (UTRACS) database and engage in proactive outreach efforts to inform these certified firms of opportunities.

4. Send letters to DBE suppliers encouraging them to contact our company with proposals regarding providing goods and services and to keep a log of all letters, contacts, responses, and non-responses.

5. Encourage other suppliers who may be eligible to apply for DBE certification.

6. Make the best reasonable efforts to obtain and utilize the services of DBE businesses.

https://utracs.azdot.gov/

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

II. Company Responsibilities:

_____________ understands the requirements to comply with Public Transit Department Small Business Participation Plan and 49 CFR Part 26. The company will track and report all DBE, and/or small business participation that occurs on transit related projects as a result of a contract, procurements, purchase orders, subleases, JV, goods/services or other arrangements involving sub-tier participation. This documentation will be entered monthly into the City’s reporting program “Certification and Compliance System” at phoenix.diversitycompliance.com.

III. List of Goods and Services

The company has identified this list as potential categories of goods and services that can be purchased from small businesses and DBE certified suppliers on transit related projects:

1. ________________________________

2. ________________________________

3. ________________________________

4. ________________________________

5. ________________________________

6. ________________________________

7. ________________________________

8. ________________________________

Other commitments:

https://phoenix.diversitycompliance.com/

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

IV. DBE Firms Currently in Use

Listed below are the DBE firms and small businesses that are currently participating with the company as subcontractors, joint venture partners, suppliers of goods and services, and other business relationships.

3. ________________________________

4. ________________________________

5. ________________________________

6. ________________________________

7. ________________________________

8. ________________________________

V. Future Opportunities* for DBE Participation

The company working on a transit-related project will use the City of Phoenix and Federal databases as a starting point to locate and engage potential opportunities of DBE suppliers. Potential opportunities for DBE participation include:

*Please list scopes of work of vendor and/or goods and services area(s)

3. ________________________________

4. ________________________________

5. ________________________________

(add more lines as needed)

This list will be assessed at the next submission of the annual SBPP.

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

VI. The chart below summarizes all the expenditures made to Certified DBEs and small businesses during the past year.

Company Name Point of contact Email DBE or SBE Total Amount Paid During the Past Year (MM-DD-YYYY to MM-DD-YYYY)

VII. Annual DBE/Small Business Participation Plan Submission

The contractor shall complete and submit an updated SBPP, including any associated supporting documentation requested by the Agency or Subrecipient, on an annual basis from the contract start.

302 N. 1st Avenue, 9th Floor • Phoenix, AZ 85003-1611 • (602) 262-7242 • Fax: (602) 495-2002 • TTY (602) 534-1557

VIII. Contract Liason

____________________ will be responsible for submitting the Small Business Participation Plan on a yearly basis and other required reports by the contracting agency.

a. Contact Information:

Name: _________________________________________________________

Phone: _____________________ Cell:________________________

E-mail: _________________________________________________________

Address: ________________________________________________________

Date: ________________________

**Please submit all supporting documentation with your SBPP.**