Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- County-Wide Roofing Replacement and Repair
- Solicitation number
- 25-0354-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a sample Application and Certificate for Payment form for Pinellas County, Florida, designed to be used by contractors for requesting payment on county projects. The form provides a standardized template for documenting payment details, including a change order summary section and a payment summary section where contractors can record original agreement amounts, retainage percentages, total earned funds, previous payments, and current payment due.
The form serves as both a payment request and a legal release document, where the contractor certifies that previous payments have been used to pay for materials and work performed, and releases the Board of County Commissioners from future claims related to the specific project period. The document requires signatures and approvals from multiple parties, including the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, Pinellas County Public Works, and the department director, ensuring multiple levels of review and verification before payment is processed.
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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 .