Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0112-ITB-C STEP 2
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for contractors to request payment for work completed on a county project. The form provides a structured template for documenting change orders, payment summaries, and contractual releases, with sections for recording the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form requires signatures and approvals from multiple parties, including the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director.
The payment application serves as both a financial record and a legal release, whereby the contractor certifies that previous payments have been used to pay obligations for materials and work performed. The document includes a comprehensive waiver clause where the contractor releases Pinellas County and its Board of County Commissioners from all potential claims, demands, damages, costs, and expenses related to the project for the specified payment period. The form is designed to provide transparency, accountability, and legal protection for both the contractor and the county during the payment process.
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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 .