Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Guardrail Services and Materials State and local contract opportunity
- Solicitation number
- 25-0288-ITB- C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request payment for work completed on a county project. The form provides a structured template for documenting payment details, including change orders, original agreement amount, 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 approvals from a consultant, project manager, and department director.
The payment application serves as both a request for payment and a legal release, where the contractor waives future claims against Pinellas County for the specified payment period. The form allows for tracking of project financials through detailed summaries of change orders, payment progression, and total project costs. While specific to the guardrail services and materials contract, this document represents a standard financial documentation process used by Pinellas County to manage contractor payments, ensure proper accounting, and protect the county's interests by obtaining a comprehensive release with each payment application.
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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 .