Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- ARPA Paving and Local Roads - PID 005651A
- Solicitation number
- 23-0281-ITB-CP
- Issued by
- Pinellas County, 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 specific project. The form is structured to capture details about change orders, payment periods, and financial summaries, including original agreement amounts, retainage percentages, and current payment due. It provides spaces for the contractor to certify that previous payments have been used to pay for materials and work performed, and includes sections for approval by a consultant, design professional, engineering project manager, and department director.
The application serves as both a payment request and a legal release, where the contractor waives future claims against Pinellas County for the specified payment period. While the specific payment amount is not filled in, the form is tied to the ARPA Paving and Local Roads project (PID 005651A), which involves milling and resurfacing five local subdivision roadways in the Ridgecrest, Lealman, and Highpoint communities. The project is funded either fully or partially by Coronavirus Local Fiscal Recovery Funds from the American Rescue Plan Act (ARPA), indicating federal grant funding is supporting the infrastructure improvement efforts.
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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 .