Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0683-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
The document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request payment for work completed on county projects. The form provides a standardized template for documenting payment details, including change orders, original agreement amount, retainage, and current payment due. It is specifically related to the FY2025-2027 Countywide Pavement Preservation project, which aims to improve roadway conditions through milling, resurfacing, and potential road base reconstruction of designated existing roadways.
The payment application serves as both a request for payment and a release of claims, allowing the contractor to certify that previous payments have been used to pay for materials and work performed. The form requires approval from multiple parties, including a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. While specific pricing details are not filled in on this sample form, the document provides a framework for tracking project expenses, change orders, and progress payments within the context of the county's pavement preservation program.
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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
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