Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 25-0681-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractors to request payment for work completed on a county project. The form provides a comprehensive template for tracking project financials, including sections for change order summaries, payment summaries, and certification of payment requests. It requires details such as payment application number, purchase order number, payment period, original agreement amount, retainage percentage, total earned less retainage, and current payment due.
The form serves as both a financial tracking document and a legal release, where the contractor certifies that previous payments have been used to pay obligations for materials and work performed. By completing and signing this document, the contractor releases Pinellas County and its Board of County Commissioners from all claims, demands, damages, costs, and expenses related to the performance of the agreement for the specified payment period. The document requires signatures and approvals from the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director to process the payment request.
View the file
Other files
Show all 25
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .