Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0742-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County Department, designed for use in contract payment processing. The form provides a template for contractors to submit payment requests, documenting project costs, change orders, and payment summaries. It includes sections for tracking the original agreement amount, retainage, previous payments, and the current payment due, with spaces for approvals from the consultant, engineering project manager, and department director.
The application serves as both a payment request and a legal release, where the contractor certifies that previous payments have been used to pay for materials and work performed, and waives all current and future claims against Pinellas County related to the project. The form is specifically linked to the Cured-In-Place Pipe (CIPP) Stormwater Pipe Rehabilitation project, which aims to rehabilitate the county's stormwater and sanitary sewer infrastructure. The document provides a standardized method for contractors to request payment and formally acknowledge the completion of work during the specified payment period.
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APPENDIX 3 - SAMPLE APPLICATION FOR PAYMENT
APPENDIX 3 – SAMPLE APPLICATION FOR PAYMENT
APPLICATION AND CERTIFICATE FOR PAYMENT
From (Contractor Name) Pinellas County Department
Payment Application Number Purchase Order Number
Payment Period From:
to
CHANGE ORDER SUMMARY PAYMENT SUMMARY
Change Order #
Date Approved
Additions Deductions Original Agreement Amount $
Retainage __________ %
Total Earned Less Retainage $
Less Previous Payments $
TOTAL
NET CHANGE Current Payment Due $
I certify that the payment requested is in APPLICATION FOR PAYMENT APPROVED BY:
accordance with the terms of the agreement dated _____________ and that previous Consultant or Design Professional/Engineer of Record payments have been used to pay obligations for materials supplied and work performed in conjunction with this project. In accordance
Pinellas County ________ (Dept) Engineering Project Manager with the contract documents and in consideration of _____________ ____ paid.
___________________ (“Contractor”) releases
Pinellas County Public Works and waives for itself and its subcontractors, materialmen, successors, and assigns, all claims demands, damages, costs and Director of ___________________ (Dept) expenses, whether in contract or in tort, against the Board of County Commissioners of Pinellas County, Florida, Ex Officio the governing Board of the Pinellas County (“County”) relating in any way to the performance of the agreement between contractors and owner, dated for the period from _________________ to
Contractor Date
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