Sample_Application_for_Payment.pdf

This is a Sample Application for Payment form used by Pinellas County, Florida for construction projects and related work. The document serves as a standardized template for contractors to request payment from the County for work performed under a contract or purchase order. The form requires contractors to document the payment application number, purchase order number, payment period, and provide a detailed change order summary showing original agreement amounts, additions, deductions, retainage percentages, previous payments, and the current amount due. Contractors must certify that payments requested align with contract terms and that previous payments were used appropriately for materials and work performed. The application requires approval signatures from the Consultant or Design Professional/Engineer of Record and the relevant Department's Engineering Project Manager or Director. Upon payment, contractors release Pinellas County Public Works and waive all claims, demands, damages, costs, and expenses related to contract performance for the specified payment period.

The form includes standard contractual language whereby contractors acknowledge the County's right to retain a percentage of payments as security and confirm compliance with contract documents and conditions. No specific pricing, set-asides, incumbent information, or funding sources are detailed within this template document, as it is designed as a blank form for use across multiple Pinellas County construction projects. The retainage percentage, original agreement amounts, and payment schedules would be populated based on individual project contracts. This application format aligns with the County's procurement practices for construction projects, including the Solid Waste Administration Building HVAC Renovation project, which implements a 5% retainage on monthly progress payments through final completion and acceptance.