Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 26-0144-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This is a Sample Application for Payment form used by Pinellas County Department in Florida for contractor payment processing. The form is designed to document payment requests from contractors performing work on county projects and requires certification that payments align with the underlying contract terms. The application includes sections for tracking change orders, detailing additions and deductions to the original agreement amount, and documenting the payment period covered. The form must be approved by both the consulting professional or engineer of record and the relevant department's project manager, as well as the Director of the applicable department before payment authorization.
The payment application incorporates a release clause in which the contractor waives all claims, demands, damages, and expenses against Pinellas County and the Board of County Commissioners related to contract performance upon receipt of payment. The form accounts for retainage deductions as a percentage of earned amounts and requires documentation of previous payments to ensure proper accounting. This standardized template is utilized in conjunction with the county's Light Electrical Commercial Repairs and Equipment contract, which establishes an as-needed repair service agreement for light commercial electrical equipment across various county-owned and leased facilities.
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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 .