Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY25 Pavement Preservation Package No 1
- Solicitation number
- 24-0757-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for documenting contractor payment requests and related project financial information. The form provides a structured template for contractors to submit payment applications, including sections for change order summaries, payment summaries, and certification of work performed and payments used for project obligations.
The form includes fields for tracking the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It also incorporates a release and waiver section where the contractor acknowledges receiving payment and releases the Board of County Commissioners from further claims related to the specific project period. The document is intended to provide a standardized method for contractors working on Pinellas County projects, such as the FY25 Pavement Preservation Package No 1, to request and document progress payments while maintaining clear financial records and legal protections for both the contractor and the county.
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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 .