Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0742-ITB-C STEP 1
- Issued by
- Pinellas County, Florida
About this file
The document is a Sample Application for Payment form from Pinellas County Public Works, designed for contractors to request payment for work performed during a specific project period. The form provides a structured template for documenting project financial 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 payment compliance and release claims against Pinellas County for the specified work period.
The form serves as a comprehensive payment application that requires approval from multiple parties, including a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. While this specific document is a sample template and does not contain actual project-specific financial details, it is linked to a Cured-In-Place Pipe (CIPP) Stormwater Pipe Rehabilitation project in Pinellas County, Florida. The form facilitates transparent financial documentation and provides a standardized method for contractors to request compensation for completed work, ensuring proper tracking and validation of project expenditures.
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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 .