5-Application for Payment.pdf.pdf

HILLSBOROUGH COUNTY

APPLICATION FOR PAYMENT

(SECTION I) PAGE ONE OF PAGE(S)

PROJECT: APPLICATION NO.:

APPLICATION DATE:

CIP NO.: BID NO.: FOR PERIOD FROM:

TO:

CONTRACTOR:

CHANGE ORDER SUMMARY CONTRACT STATUS

ORIGINAL CONTRACT SUM $

NET CHANGE BY CHANGE ORDERS

(COLUMN 3 MINUS COLUMN 4) $

CONTRACT SUM TO DATE $

1 2 3 4

NO.

DATE APPROVED BY

COUNTY ADDITIVE DEDUCTIVE

VALUE OF WORK IN PLACE $

VALUE OF STORED MATERIALS $

TOTAL EARNED $

RETAINAGE AT % $

TOTAL EARNED LESS RETAINAGE $

LESS PREVIOUS PAYMENTS $

LESS $

CURRENT PAYMENT DUE $ TOTALS

(SECTION II) CERTIFICATION BY CONTRACTOR

The undersigned Contractor certifies:

1) All amounts and items shown on this application are correct.

2) Any work performed or materials supplied have been done in accordance with the contract documents.

3) That the contractor has clear title to any materials or equipment for which the contractor is requesting payment as stored materials.

4) All amounts paid by the County to the Contractor in previous progress payments have been applied by the Contractor and its subcontractors to promptly pay, in proportionate amounts, all subcontractors, suppliers, and others who have contributed work or materials listed in the Schedule of Values of the previous Payment Applications, except as indicated on Attachment 1, which is incorporated herein, consisting of _____ page(s).

5) The Contractor will apply any sums paid by the County from this Application for Payment to subcontractors, material, suppliers, and others who have contributed work or materials included in the line items referenced in the attached Schedule of Values (less retainage, if applicable) except as indicated on Attachment 2, which is incorporated herein, consisting of ____ page(s).

CONTRACTOR:

BY:

(Title) (Date)

ATTEST:

State of __________ County of__________

Sworn to (or affirmed) and subscribed before me, by means of_ ___ ____physical presence or ____online notarization, this ____ day of ___________, 20___, by ________________________________________.

Notary Public:

My Commission Expires:

SEAL)

Personally Known OR Produced Identification Type of Identification Produced ______________________

Revised 04.20.2020

(SECTION III) CERTIFICATION BY HILLSBOROUGH COUNTY AND REPRESENTATIVES

Based on on-site observations and the data comprising this Application for Payment, the undersigned certifies that the Work has progressed to the point indicated herein and to the best of my knowledge, information and belief is in accordance with the Contract Documents and that the CONTRACTOR is entitled to payment of the amount certified herein.

Hillsborough County INSPECTOR: DATE Hillsborough County RESIDENT ENGINEER: DATE Hillsborough County PROJECT MANAGER: DATE Hillsborough County SECTION MANAGER*: DATE

(*applicable if Project Manager is a temporary employee, consultant, or 50% of payment application; otherwise N/A)

COUNTY REPRESENTATIVE:

PROFESSIONAL CONSULTANT:

BY: DATE

(See Instructions on Back)

HILLSBOROUGH COUNTY'S CONSTRUCTION APPLICATION

FOR PAYMENT INSTRUCTION

The purpose of this form is to facilitate the summary information for Hillsborough County's Construction Application for Payment. This form will be completed by the Contractor each time payment is requested for a project. This Application for Payment will be accompanied by a Schedule of Values (which provides line-item detail information for the project), Attachment 1, and Attachment 2.

SECTION I: This section will be completed by the Contractor. The Contractor will provide the information as indicated on the form.

SECTION II: This section will be completed by the Contractor. In this section, the Contractor will provide certification about the information provided in Section I. The certification will be provided in accordance with the construction Contract Documents.

SECTION III: This section will be completed to provide approval by Hillsborough County staff and/or its representative(s). Under the approval section by Hillsborough County staff:

signature/approval by a County Project Manager will always be provided. However, the signature for the Resident Engineer or the Inspector will only be provided if the County is responsible for these functions. When the County is not responsible for these functions, the approval will indicate "N/A".

Under the approval section by Hillsborough County's Representative: signature/approval will be provided by a Construction Manager when applicable. Additionally, signature/approval may also be provided by a Professional when applicable. When there is no Construction Manager or Professional responsible for such activities then the approval will indicate "N/A".

PAGE ONE OF PAGE(S)

PROJECT: ATTACHMENT 1

CIP NO: BID NO: APPLICATION NO.:

APPLICATION DATE:

CONTRACTOR: FOR PERIOD FROM:

TO:

Name of Entity Relationship

Amount in Dispute

Application for Payment No. or corresponding line item reference to Schedule of Values Explanation

-or-

This page [ ] is [ ] is not applicable.

Contractor Signature

PAGE ONE OF PAGE(S)

PROJECT: ATTACHMENT 2

CIP NO: BID NO: APPLICATION NO.:

APPLICATION DATE:

CONTRACTOR: FOR PERIOD FROM:

TO:

Name of Entity Relationship

Amount in Dispute

Corresponding line item reference to Schedule of Values Explanation

-or-

This page [ ] is [ ] is not applicable.

Contractor Signature

HILLSBOROUGH COUNTY, FLORIDA

APPLICATION FOR PAYMENT PAGE OF PAGES

SCHEDULE OF VALUES

PROJECT NO. APPLICATION NO.

PROJECT: APPLICATION DATE:

BID NO. FOR PERIOD FROM:

CONTRACTOR: TO:

A B C D E F G H I J K L M N O P

Item No. Description Of Work Unit Price

CONTRACT SUM TO DATE WORK IN PLACE STORED MATERIALS

Comp

CONTRACT AAR APPLICATIONS CHANGE ORDER APPLICATIONS

Quantity Value Quantity Value Quantity Value No. Quantity Value No. Quantity Value

PAGE TOTALS:

CUMULATIVE TOTALS: