Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 25-0770-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a sample Application for Payment form for Pinellas County, Florida, specifically designed for use in contract payment processing within the county's Public Works Department. The template provides a standardized framework for contractors to request payment for work completed, with sections for documenting change orders, payment summaries, and contractual certifications. The form includes spaces to record payment application details such as the payment period, original agreement amount, retainage percentage, total earned funds, previous payments, and current payment due.
The payment application form serves as both a financial request and a legal release document, wherein the contractor certifies that previous payments have been used to cover materials and work performed, and releases the Board of County Commissioners from future claims related to the specific contract period. The document requires approval signatures from multiple parties, including a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director, ensuring multiple levels of verification and accountability in the payment process. While this is a sample template, it appears directly linked to the Drawbridge Services contract for preventative maintenance and emergency repair services for three bascule bridges in Pinellas County.
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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 .