ARKANSAS STATE HIGHWAY AND TRANSPORTATION DEPARTMENT CERTIFICATE OF PAYMENT
JOB JOB NAME ORIGINAL CONTRACT AMOUNT $
DBE GOAL $
FINAL PAYMENT TO DBEs The undersigned Contractor on the above mentioned project hereby certifies that the following amount(s) were paid to:
Total Paid to DBEs
$ $ $ $ $ $ $ $ $ $ $ $
Only payments related to work, services, or material actually provided by DBE firms should be shown. Payments under second tier subcontracts from DBE firms to non-DBE firms should not be included. DBE prime Contractors should include the value of work performed by its own forces.
Contractor: Signature: Typed or Printed Name: Title:
This certificate shall be submitted through the Resident Engineer who will attach it to the original copy of the final estimate for payment.
If goal not met, brief explanation: