Sample_Application_for_Payment.pdf

This document is a Sample Application for Payment form used by Pinellas County Department for construction and engineering projects in Florida. The form serves as the official payment request and certification mechanism for contractors performing work under agreements with Pinellas County Public Works. The application captures essential project information including the contractor name, purchase order number, and payment period, while documenting changes to the original agreement through a change order summary section. The form requires certification from both the contractor and county representatives, including the Engineering Project Manager and Department Director, confirming that payment requests comply with contract terms and that previous payments were appropriately applied to materials and work performed on the project.

The payment application establishes a formal release and waiver mechanism wherein the contractor, upon receipt of payment, releases Pinellas County and the Board of County Commissioners from all claims, demands, damages, and expenses—whether contractual or tort-based—related to the agreement performance for the specified payment period. The form calculates the current payment due by establishing the total earned amount, subtracting retainage at a specified percentage, deducting all previous payments, and accounting for any change order additions or deductions to the original agreement amount. This standardized payment application ensures compliance with contract terms and provides documented evidence of payment authorization and contractor certification across Pinellas County's infrastructure projects, including the FY 2027 Pavement Preservation program.