CERTIFICATION OF FINAL DISADVANTAGED BUSINESS ENTERPRISE (DBE… · 2019. 8. 29. · Name of DBE...
Transcript of CERTIFICATION OF FINAL DISADVANTAGED BUSINESS ENTERPRISE (DBE… · 2019. 8. 29. · Name of DBE...
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BECO Form 210PS (Rev 5-1-19)
The undersigned Consultant on Contract # herby, certifies that full payment was made, to the firm indicated for material and/or work performed under this project's contract as follows:
DBE FIRM AZ UTRACS Vendor Registration # _______________________________
Name of DBE Firm
This certificate 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 minim um of three years from project acceptance date. In the event the DBE was not paid in accordance with affidavits submitted by the prime contractor, all documentation supporting the contractor's position should be submitted.
I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY OTHER APPLICABLE STATE OR FEDERAL LAWS, THAT THE STATEMENT MADE ON THIS DOCUMENT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
Name: Title:
Signature:
Date:
The undersigned subconsultant/supplier/manufacturer for the above named project hereby certified that paymentswere received and/or justification by contractor is correct.
I DECLARE UNDER PENALTY OF PERJURY IN THE SECOND DEGREE, AND ANY OTHER APPLICABLE STATE OR FEDERAL LAWS, THAT THE STATEMENT MADE ON THIS DOCUMENT ARE TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE.
DBE Firm Name:
Check One:
Name: Title:
Signature:
Date:
ARIZONA DEPARTMENT OF TRANSPORTATION CERTIFICATION OF FINAL DISADVANTAGED BUSINESS ENTERPRISE (DBE) PAYMENTS
Professional Services/Design Contracts(Submit one form for each DBE involved in the contract)
was paid the amount of
Consulant Company Name: Check One: Consultant Subconsultant
Subconsultant/Supplier/Manufacturer Lower-tier Subconsultant/Supplier/Manufacturer
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The undersigned Consultant on Contract: DBE FIRM AZ UTRACS Vendor Registration: Name of DBE Firm: was paid the amount of: Consulant Company Name: Name: Title: Date: DBE Firm Name: Name_2: Title_2: Date_2: Subcon_Supp_Man: OffLow-tier_Subcon_Supp_Man: OffConsultant_Yes: OffSubconsultant_Yes: OffReset: