Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- SCB Replacement of Generator Controls and Switchgear (PID 004906DE) State and local contract opportunity
- Solicitation number
- 25-0073-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractor payment processing related to the South Cross Bayou Advanced Waste Reclamation Facility (AWRF) Generator Controls and Switchgear Replacement project. The form provides a standardized template for contractors to request payment, detailing change orders, payment summaries, and a comprehensive release of claims against Pinellas County for work performed during a specific contract period.
The payment application includes sections for tracking the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form requires certification by the contractor that previous payments have been used to pay obligations for materials and work, and includes spaces for approval by a consultant, design professional, engineering project manager, and department director. The document serves as both a payment request and a legal document wherein the contractor releases and waives potential claims against Pinellas County related to the project's performance.
View the file
Other files for this state and local contract opportunity
Show all 22
On GovTribe
Work with this file on GovTribe
- 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 .