Sample_Application_for_Payment.pdf

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Attached to
Solid Waste Industrial Waste Treatment Facility (IWTF) Intake Pump Station (IPS) PID: 002423A
Solicitation number
23-0273-ITB-CP
Issued by
Pinellas County, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form for Pinellas County, Florida, designed for contractors to request payment for work performed on a specific 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 payment is in accordance with agreement terms and that previous payments have been used to pay for materials and work.

The form includes a release and waiver section where the contractor releases Pinellas County and the Board of County Commissioners from all claims, demands, damages, costs, and expenses related to the project performance. The document requires signatures and approvals from the contractor, a consultant or design professional/engineer of record, the Pinellas County Engineering Project Manager, and the department director. It is intended to provide a standardized method for contractors to request and document payments for work completed on county projects, ensuring transparency and proper financial tracking.

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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 .