Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0791-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, specifically Appendix 3 of a contract document. The form is designed for contractors to request payment for work completed during a specific payment period, with sections for documenting change orders, payment summaries, and contractual certifications. The form provides a structured template for contractors to detail their payment request, including original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due.
The payment application requires multiple approvals, including certification from the contractor, verification by a consultant or design professional/engineer of record, and sign-off from a Pinellas County Engineering Project Manager and department director. The form includes a release and waiver clause wherein the contractor releases Pinellas County from claims related to the project for the specified payment period. While no specific dollar amounts or project details are filled in, the form is a standardized mechanism for contractors to request and document periodic payments for work completed under a county contract.
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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 .