Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Palm Harbor Recreation Center Addition State and local contract opportunity
- Solicitation number
- 26-0011-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a sample Application and Certificate for Payment form for a Pinellas County Department contract. The form provides a template for contractors to request payment for work completed, with sections for tracking change orders, recording payment summaries, and documenting payment certification. The form includes spaces to record the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due.
The payment application 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 Pinellas County from any further claims related to the project for the specified payment period. The form requires approval signatures from the Consultant or Design Professional/Engineer of Record, the Pinellas County Engineering Project Manager, and the Department Director, providing a comprehensive documentation trail for the payment process.
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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 .