Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
Utilities light electrical work
Solicitation number
25-0201-ITB-C
Issued by
Pinellas County, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form from Pinellas County, specifically designed for contractors to request payment for work completed on a project. The form is structured to capture detailed financial information including change orders, payment summaries, and project-specific payment details. It serves as both an application for payment and a release of claims document, allowing the contractor to request compensation while simultaneously waiving future claims related to the specific project period.

The payment application template includes sections for tracking the original agreement amount, retainage percentage, total earned amounts, previous payments, and current payment due. The document 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 form is part of a broader procurement process for utilities light electrical work, where Pinellas County Utilities Department intends to establish a contract with multiple individual contractors for repair of light commercial electrical equipment at various county-owned and leased facilities on an as-needed basis.

View the file

Other files

File Type Posted
Utilities_light_electrical_work.pdf PDF
25-0201_-_Light_Electrical_Commercial_Repairs,_Installation,_and_Equipment_-_Insurance_Requirements_I.pdf PDF
Non-Competitive_Oversight_Committee_Justification_Form.docx DOCX document
Airport_Security_Program.pdf PDF
Sample_Change_Order.pdf PDF
Bid_Submittal_Form-JOC.pdf PDF
Florida_Trench_Safety_Form.pdf PDF
SBE_Compliance_Form.pdf PDF
Affdavit_of_Release_and_Guarantee.pdf PDF
E-Verify_Affidavit.pdf PDF
OpenGov_Fillable-_Final.pdf PDF
Show all 11

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 .