Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 24-1061-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
The document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request compensation for work performed on county projects. This standard payment application template provides a structured format for documenting project financial details, including change orders, payment summaries, and contractual releases. The form is specifically associated with the Annual Water and Reclaimed Water Repairs and Extensions project for Fiscal Years 2024-2026, which involves repairing, rehabilitating, and replacing potable and reclaimed water pipes at various county locations.
The payment application includes sections for tracking original agreement amounts, retainage percentages, total earned amounts, previous payments, and current payment due. It requires certification from the contractor that previous payments have been used to pay for materials and work, and includes a comprehensive waiver of claims against Pinellas County for the specific payment period. The form is designed to be approved by multiple parties, including a consultant or design professional, the county engineering project manager, and the department director, ensuring multiple levels of financial and project oversight.
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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
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