Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Pump Station 182 Rehabilitation (PID 005221A)
- Solicitation number
- 25-0422-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a sample application for payment form template used by Pinellas County Department for contractor payment requests. The document serves as a standardized format for contractors to submit payment applications to Pinellas County, including fields for payment application numbers, purchase order numbers, payment periods, and change order summaries with additions and deductions. The form requires approval signatures from the Consultant or Design Professional/Engineer of Record, Pinellas County Department Engineering Project Manager, Pinellas County Public Works, and the Director of the relevant department.
The payment summary section includes fields for the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form incorporates a certification statement where the contractor attests that the payment request complies with agreement terms and that previous payments have been used appropriately for materials and work performed. Additionally, the contractor must provide a release and waiver of claims against the Board of County Commissioners of Pinellas County for the specified payment period, protecting the county from future claims related to the work performed during that period.
View the file
Other files
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .