Sample_Application_for_Payment.pdf

This is a Sample Application for Payment form utilized by Pinellas County, Florida for construction and renovation projects. The form serves as a standardized template for contractors to request payment from the County for work performed and materials supplied on contracted projects. The application requires contractors to document the payment application number, purchase order number, payment period, and a comprehensive change order summary detailing any additions or deductions to the original agreement amount. The form mandates that contractors certify compliance with contract terms, document all previous payments received, calculate retainage amounts (as specified in the contract), and provide the total net amount due for the current payment period. Required approvals must be obtained from the County's Department Engineering Project Manager, Consultant or Design Professional/Engineer of Record, and the Director of the respective department before payment authorization.

The document includes a release and waiver clause whereby the contractor, upon receiving payment, releases Pinellas County Public Works and the Board of County Commissioners from all claims, demands, damages, costs, and expenses related to contract performance for the specified payment period. This form is designed for use with projects such as the Solid Waste Administration Building HVAC Renovation (ITB-C #26-0394-ITB-C), where retainage is established at 5% of monthly progress payments until final project completion and acceptance. The standardized format ensures consistent documentation and financial accountability across Pinellas County's capital improvement and construction projects, with the contractor's certification serving as acknowledgment that payment obligations for materials and labor have been satisfied in accordance with contract specifications.