Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0356-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, designed for contractors to submit payment requests for projects. The form provides a structured template for documenting payment details, including change orders, payment summaries, and a certification of work performed. The form is specifically related to the Cured-In-Place Pipe (CIPP) Stormwater Pipe Rehabilitation project, which aims to rehabilitate stormwater and sanitary sewer infrastructure through pipeline lining services.
The payment application form includes sections for tracking the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It also includes a release and waiver clause for the contractor, acknowledging that previous payments have been used to pay for materials and work performed. The form requires approval from a consultant or design professional, a Pinellas County Engineering Project Manager, and the department director, ensuring multiple levels of verification for the payment request.
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Text version
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
File details come from the government source that posted it. Updated .