Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 26-0361-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Sample Application for Payment form issued by Pinellas County Department in Florida for use by contractors submitting payment requests on County projects. The document serves as a standardized template for contractors to request payment for work completed and materials supplied under their contract agreements. The form requires contractors to provide the contractor name, payment application number, purchase order number, and payment period dates. Contractors must document all change orders with approval dates, additions, and deductions, and calculate the total earned amount less any retainage percentage established in the original agreement. The form requires certification that payment is in accordance with contract terms and that previous payments were properly applied to project obligations.
The application requires approval signatures from the Pinellas County Engineering Project Manager, the relevant Department Consultant or Design Professional/Engineer of Record, and the Director of the respective department. Upon payment approval and receipt of funds, the contractor releases Pinellas County Public Works, the Board of County Commissioners, and the County from all claims, demands, damages, costs, and expenses related to the performance of the agreement for the specified payment period. This payment application form is applicable to the FY 2027 Pavement Preservation Package 1 project, which encompasses four paving locations totaling approximately 38.55 lane miles of roadway consisting of two arterial and two local neighborhood projects within Pinellas County.
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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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