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 for Pinellas County, specifically designed for a contractor to request payment for work completed on a project. The form provides a template for documenting payment details, including a change order summary section and a payment summary section where contractors can record the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form requires signatures and approvals from multiple parties, including the consultant or design professional, the Pinellas County Engineering Project Manager, and the director of the relevant department.
The form serves as both an application for payment and a release of claims, wherein the contractor certifies that previous payments have been used to pay obligations for materials and work performed. By completing and signing the document, the contractor releases and waives all claims, demands, damages, costs, and expenses against the Board of County Commissioners of Pinellas County for the specific period of work covered by the payment application. The document is structured to provide a comprehensive and standardized method for contractors to request payment and acknowledge the fulfillment of contractual obligations.
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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 .