Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY2026 Airfield Pavement Rehabilitation
- Solicitation number
- 26-0722-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 contractor payment processing on construction and professional services projects. The form serves as a standardized template for contractors to request payment reimbursement and certify compliance with contract terms and conditions. Contractors must submit applications detailing the original agreement amount, any approved change orders with associated additions or deductions, total earned amounts, retainage percentages, previous payments received, and the current payment due. The form requires certification that payment requests align with the executed contract agreement and that all previous payments were properly applied to project obligations for materials and labor.
The application requires approval by multiple Pinellas County officials, including the Engineering Project Manager, Consultant or Design Professional/Engineer of Record, and the Director of the relevant department, before payment authorization. Upon approval and receipt of payment, the contractor executes a release waiving all claims, demands, and damages against the Board of County Commissioners of Pinellas County and Pinellas County Public Works relating to project performance for the specified period, extending this release to subcontractors, materialmen, successors, and assigns. The form requires documented signature and date fields for both contractor certification and departmental approval authorities.
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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
File details come from the government source that posted it. Updated .