Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY 2025 - Pavement Preservation - Package 4
- Solicitation number
- 25-0669-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 structured template for documenting payment details, including change orders, payment periods, original agreement amounts, retainage percentages, 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.
This payment application form is specifically related to the FY 2025 Pavement Preservation - Package 4 project, which involves milling and resurfacing approximately 34.98 lane miles of roadway across four locations in Pinellas County. The form allows for detailed tracking of financial transactions, including a comprehensive breakdown of additions, deductions, and net changes to the original agreement. The document also includes a release and waiver clause, whereby the contractor releases the Board of County Commissioners from claims related to the project performance, ensuring clear financial documentation and liability management for the roadway improvement initiative.
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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
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