Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Solicitation number
- 26-0362-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 contractors and design professionals to request payment under state and local contracts. The document serves as the official payment certification mechanism for the Fiscal Year 2027 Pavement Preservation - Package 2 project, which involves milling and resurfacing work across four paving locations in Pinellas County, Florida, encompassing approximately 33.27 lane miles of roadway consisting of one arterial and three local neighborhood projects. The application format requires contractors to document the payment application number, purchase order number, payment period dates, and provide a detailed change order summary listing any additions or deductions to the original agreement amount.
The payment application requires certification that funds are being requested in accordance with the contract terms and that previous payments have been appropriately applied to materials and labor. The form includes sections for calculating total earned amounts, retainage percentages, deductions for previous payments, and the current net payment due. Approval authority rests with the Pinellas County Engineering Project Manager and the Director of the respective department. Upon payment approval, the contractor releases Pinellas County Public Works and the Board of County Commissioners from all claims, demands, damages, and expenses related to the performance of work for the specified contract period, providing a comprehensive waiver protecting the County from further liability regarding the contractor's performance.
View the file
Other files
Show all 31
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 .