Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 25-0073-ITB-C STEP 2
- Issued by
- Pinellas County, Florida
About this file
This document is a sample Application and Certificate for Payment form for Pinellas County, specifically designed for contractor payment processing. The form provides a structured template for documenting payment requests, including sections for change order summaries, payment summaries, and certification of payment compliance. The form is intended to track project expenses, record payment periods, calculate current payment due, and provide a legal release for the contractor against the Pinellas County Board of County Commissioners.
The payment application includes spaces to record critical financial details such as the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form requires approval signatures from multiple parties, including a consultant or design professional, a Pinellas County Engineering Project Manager, and the department director. By completing this document, the contractor certifies that previous payments have been used to pay obligations for materials and work performed, and releases the county from potential future claims related to the project's performance.
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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 .