Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- STAR Center Chiller 2 Replacement STEP 2
- Solicitation number
- 23-1128-ITB-C STEP 2
- Issued by
- Pinellas County, Clewiston City, 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 payment details, including a change order summary, payment summary, and a comprehensive release of claims section. While the specific project details are not filled in, the form is intended to capture critical financial information such as the original agreement amount, retainage percentage, total earned less retainage, previous payments, and the current payment due.
The form requires multiple approvals, including a consultant or design professional/engineer of record, a Pinellas County Engineering Project Manager, and a department director. By completing and signing this document, the contractor certifies that the payment request complies with the agreement terms and that previous payments have been used to pay for materials and work performed. The document also includes a broad legal release, where the contractor waives all current and future claims against Pinellas County related to the project's performance, protecting the county from potential subsequent legal actions.
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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 .