Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 23-0394-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, designed for contractors to request payment for work completed on a project. The form provides a structured template for documenting payment details, including change orders, original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It includes sections for the contractor to certify that previous payments have been used to pay for materials and work, and includes spaces for approval by a consultant, design professional, engineering project manager, and department director.
The form serves as both an application for payment and a release of claims, where the contractor waives all current and future claims against the Pinellas County Board of County Commissioners related to the performance of the agreement. While specific dollar amounts are not filled in on this sample form, it is structured to allow precise financial tracking and documentation for a contract, with provisions for recording change orders, calculating net payments, and formally acknowledging the completion of work and receipt of payment. The form appears to be part of the documentation for the Open Conveyance Contract Maintenance project (PID 001922B), which involves stormwater management system maintenance activities in Pinellas County.
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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
File details come from the government source that posted it. Updated .