Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Ridgemoor Blvd and Brooker Creek at Brooker Creek Bridge #154153 Bridge Replacement Project (PID 005749A)
- Solicitation number
- 26-0506-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This is a Sample Application for Payment form used by Pinellas County Department for contractor payment requests related to construction projects. The form is designed for contractors to submit periodic payment applications during the performance of work under county agreements. The application requires contractors to document the payment period, change orders with approval dates and associated additions or deductions to the original agreement amount, and a detailed payment summary showing total earned amounts, retainage deductions, previous payments, and the current payment due. The form must be certified by the contractor and approved by the appropriate county engineering project manager and department director before payment authorization.
The form establishes a release and waiver mechanism whereby contractors, upon receipt of payment, release Pinellas County Public Works and the Board of County Commissioners from all claims, demands, damages, costs, and expenses related to performance of the contract for the specified payment period. Retainage is withheld from payments at a percentage determined by the county, with the exact rate to be specified in individual contracts. The application serves as the standard payment processing document for county construction projects, including federally funded Local Agency Program (LAP) projects administered through the Florida Department of Transportation, such as bridge replacement initiatives.
View the file
Other files
Show all 44
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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
File details come from the government source that posted it. Updated .