Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0537-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, designed for use in documenting contract payments, specifically related to the Federal Open Channel Drainage Repair Work Order Contract - Package 1. The form provides a standardized template for contractors to submit payment requests, tracking changes, retainage, and documenting the progressive payment process for a specific project period. The form includes sections for change order summaries, payment summaries, and certification of payment compliance, with designated approval lines for a consultant, engineering project manager, and department director.
The payment application serves as both a financial request and a legal release document, wherein the contractor certifies that previous payments have been used to cover project obligations for materials and work performed. The form includes provisions for tracking the original agreement amount, calculating retainage, documenting less previous payments, and determining the current payment due. By completing and signing this document, the contractor releases Pinellas County from future claims related to the specific payment period, ensuring a clear financial transaction and legal closure for the completed work segment.
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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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