Sample_Application_for_Payment.pdf

This is a sample application for payment form used by Pinellas County, Florida for construction and engineering projects. The form serves as a standardized template for contractors to request payment for work performed under county contracts. The application requires contractors to provide essential project information including the contractor name, payment application number, purchase order number, and payment period dates. Contractors must document change orders with their dates of approval, additions, and deductions, and provide a comprehensive payment summary showing the original agreement amount, retainage percentage, total earned amounts, previous payments, and the current payment due. The form requires certification by both the contractor and relevant county department officials, including the Engineering Project Manager and Director, and includes a release clause whereby contractors waive all claims against Pinellas County related to contract performance for the payment period specified. The application must reference the underlying contract date and performance period, establishing a clear audit trail for all project expenditures and payment reconciliation.

The form implements a retainage system whereby the county withholds a specified percentage of payments until final project completion, consistent with the 5 percent retainage policy referenced in the South Cross Bayou generator controls project. Payment processing follows Florida's Local Government Prompt Payment Act with net 45-day payment terms, and contractors may utilize the county's ePayables credit card program for payment receipt. The sample application template does not specify pricing terms, set-asides, or funding sources, as it functions as a generic payment documentation instrument applicable across multiple Pinellas County projects regardless of contract value or project scope. The form's primary purpose is to establish uniform documentation standards for payment requests, change order tracking, and contractor-county payment reconciliation across the county's capital improvement and professional services contracts.