Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Ridgecrest YMCA Elevator Modernization
- Solicitation number
- 26-0529-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This is a Sample Application for Payment form used by Pinellas County Department for contractor payment requests related to state and local projects in Florida. The document serves as a standardized template for contractors to submit payment applications during the execution of contracts with Pinellas County. The form requires contractors to document the payment application number, associated purchase order number, and the payment period covered by the request. It includes sections for change order tracking, with fields to record change order numbers, approval dates, and the dollar amounts of additions and deductions to the original agreement amount.
The payment summary section requires contractors to calculate total earned amounts, subtract applicable retainage percentages, deduct previous payments, and specify the current payment due. The form requires certification by the contractor that payments are in accordance with the contract terms and that previous payments were properly applied to materials and work performed. Approval signatures are required from the Pinellas County Engineering Project Manager and the Director of the applicable department. The document includes a release clause whereby contractors and their subcontractors waive claims against Pinellas County and the Board of County Commissioners related to project performance for the specified payment period. This standardized form facilitates organized payment processing and dispute resolution for Pinellas County construction and professional services contracts.
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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 .