Contractors_Application_for_Payment.pdf
PDF 129 KB Posted
- Attached to
- Rob Sullivan Park Maintenance Barn State and local contract opportunity
- Solicitation number
- 05-15
- Issued by
- Volusia County, Florida
About this file
This is a Contractor's Application for Payment form issued by the City of DeBary, Florida for Bid #05-15, the Rob Sullivan Park Maintenance Barn project. The project involves the delivery and installation of a 25' x 40' x 14' A-frame steel building, with permits to be handled by the City. The application form serves as the standard mechanism for contractors to request progress payments during project execution and provides line items for tracking the original contract price, net change orders, completed work to date, retainage amounts, previous payments, and the current amount due.
The application requires contractors to provide detailed financial accounting including the original contract price, any change orders, total earned amounts less retainage, and previous payments approved. Contractors must submit affidavits under penalty of perjury confirming that all previous payments have been applied to discharge obligations and that all materials and equipment are free of liens and claims. The form requires notarization and approval signatures from project management. Monthly applications must include an updated project schedule and partial lien waivers from the contractor and all subcontractors and suppliers, while final applications require complete lien releases, surety consent to final payment, and completed material and workmanship bonds. The form includes a dedicated section for listing all subcontractors, suppliers, materialmen, and equipment suppliers with their respective work amounts.
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Text version
City of Debary – Rob Sullivan Park Maintenance Barn (Bid # 05-15)
SECTION 00625
CONTRACTOR'S APPLICATION FOR PAYMENT
AGREEMENT TITLE City of DeBary Rob Sullivan Park Maintenance Barn
BID NO. / CONTRACT NO. 05-15
CONTRACTOR
PAYMENT REQUEST NO.
PERIOD ENDING DATE
STATEMENT OF WORK
1. Original Contract Price
2. Net Change Order
3. Current Contract Price
4. Total Completed and Stored to Date
5. Amount Retained
6. Total Earned Less Retainage
7. Previous Payments Approved
8. Amount Due This Payment
9. Balance to Finish, Less Retainage (Line 3 Minus Line 4)
CONTRACTOR’S AFFIDAVIT
The undersigned Contractor hereby swears under penalty of perjury that (1) all previous progress payments received from the Owner on account of Work performed under the Agreement referred to above have been applied by the Contractor to discharge in full all obligations of the Contractor incurred in connection with Work covered by prior Application for Payment under said Agreement, being Applications for Payment numbered 1 through inclusive; and, (2) all materials and equipment incorporated in said Project or otherwise listed in or covered by this Application for Payment are free and clear of all liens, claims, security interests and encumbrances; (3) all previous progress payments have been applied by the Contractor to pay in full (less retainage) all amounts owed to its Subcontractors, Suppliers, Materialmen and Equipment Suppliers reflected (and listed) in prior Applications for Payments; and (4) all information provided on the Subcontractor and Supplier Listing which is included in this Application for Payment is true and correct.
CONTRACTOR: (SEAL)
By (Signature of Authorized Representative) Date
Printed Name and Title
COUNTY OF
STATE OF FLORIDA
Before me on this day of , , appeared , who is personally known to me, or has produced as identification and who did (did not) take an oath who, being duly sworn did depose and say that he/she is the of the Contractor above-mentioned; that he/she executed the above Application for Payment and statement on behalf of said Contractor; and that all of the statements contained therein are true, correct and complete.
(Notary Public in and for the County and State Aforementioned)
SEAL My commission expires:
PAYMENT OF THE AMOUNT REQUESTED ABOVE IS RECOMMENDED FOR APPROVAL:
By Date
By Date
SUBCONTRACTOR AND SUPPLIER LISTING
The following is a list of Subcontractors, Suppliers, Materialmen and Equipment Suppliers who have performed Work or provided Materials, Supplies, or Equipment during time period represented by this Application and the dollar amount of the work applied for (attach additional sheets as necessary to provide a complete list).
NAME ADDRESS AMOUNT
REQUIRED ATTACHMENTS
Monthly Application For Payment:
1. Updated Project Schedule
2. Contractor’s Partial Release of Lien
3. All applicable Subcontractor/Vendor’s Waivers of Lien (Partial)
Final Application For Payment:
1. Contractor’s Release of Lien (Final and Complete)
2. All applicable Subcontractor/Vendor’s Waivers of Lien (Final and Complete)
3. Consent of Surety to Final Payment
4. Completed Material and Workmanship Bond
END OF SECTION
File details come from the government source that posted it. Updated .