Sample_Application_for_Payment.pdf

This is a Sample Application for Payment form used by Pinellas County Department in Florida for processing contractor payments on public works projects. The form serves as the official mechanism for contractors to request payment and for the county to authorize and process those payments. Contractors must submit applications detailing the payment period, work completed, and materials supplied during the specified contract period. The form requires approval from the Engineering Project Manager and the Department Director before payment authorization. Contractors are required to certify that all requested payments comply with the original agreement terms and that previous payments have been properly applied to project obligations.

The payment application process includes provisions for change order tracking, retainage calculations, and cumulative payment documentation. Contractors must account for the original agreement amount, any approved change orders with additions or deductions, total earned amounts, applicable retainage percentages, and previous payments received before calculating the current payment due. Upon submission and approval, the contractor releases Pinellas County Public Works and the Board of County Commissioners from all claims, demands, damages, costs, and expenses related to the agreement performance for the specified payment period. This form is a standard administrative tool for managing financial transactions between Pinellas County and contractors performing work on county infrastructure projects.