Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY2026 Pavement Preservation Package 4
- Solicitation number
- 25-0634-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, designed for contractors to submit periodic payment requests for county projects. The form provides a standardized template for documenting project financial details, including change orders, payment summaries, and certification of work completed. It allows contractors to detail the original agreement amount, calculate retainage, track previous payments, and specify the current payment due.
The form includes sections for approvals from various county officials, including the Consultant or Design Professional, the Engineering Project Manager, and the Department Director. It also contains a legal release statement where the contractor waives claims against Pinellas County for the specific payment period. While this is a sample template, it is specifically related to the FY2026 Pavement Preservation Package 4, which involves five paving locations totaling approximately 29.54 lane miles of roadway within Pinellas County, Florida.
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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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