Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Infrastructure Repair Work Order Contract
- Solicitation number
- 26-0208-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 contractors to request payment under infrastructure repair work order contracts. The form serves as an official payment certification document where contractors submit payment applications for work performed on reconstruction and repair projects including concrete repairs, site cleanup, milling and resurfacing, landscape work, fencing, sidewalk repairs, ADA ramps, sheet pile installation, and related incidental items. The application requires contractors to document the payment period, itemize any approved change orders with associated additions or deductions, and provide a detailed payment summary showing the original agreement amount, total earned amount, retainage percentage, previous payments, and the current payment due.
The form establishes a structured payment certification process requiring signatures from both the contractor and appropriate Pinellas County officials, including the Engineering Project Manager and Director of the relevant department. By submitting the application, the contractor certifies that the requested payment complies with contract terms and that previous payments were properly applied to materials and labor. Notably, the form includes a release clause wherein the contractor waives all claims, demands, damages, and expenses against Pinellas County and its Board of County Commissioners related to contract performance for the specified payment period. This comprehensive release applies to the contractor and all subcontractors, materialmen, successors, and assigns, establishing a condition precedent to payment authorization.
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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
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