Sample_Application_for_Payment.pdf
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- Solicitation number
- 25-0669-ITB-C STEP 2
- 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, specifically designed for contractors to request payment for work completed on a county project. The form provides a structured template for documenting payment details, including a change order summary section, payment summary section, and a comprehensive release of claims. The form requires completion of key information such as payment application number, purchase order number, payment period, and specific financial details like original agreement amount, retainage percentage, total earned less retainage, and current payment due.
The document serves as a standardized financial document that allows contractors to formally request payment from Pinellas County while simultaneously providing a legal release of claims for the specific payment period. The form includes spaces for approvals from multiple parties, including a consultant or design professional, the county engineering project manager, and the department director. By completing this form, the contractor certifies that previous payments have been used to pay obligations for materials and work performed, and releases the county from any further claims related to the specific performance period covered by the payment application.
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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 .