Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY 2026 Pavement Preservation Package 3
- Solicitation number
- 25-0072-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a sample Application and Certificate for Payment form from Pinellas County, designed for use in contract payment processing. The template is structured to capture detailed financial information related to a contract, including payment periods, change orders, and payment summaries. It provides a standardized mechanism for contractors to request payment, documenting the total agreement amount, retainage percentage, total earned funds, previous payments, and current payment due.
The form includes critical financial tracking elements and serves as both a payment request and a legal release document. It requires signatures from multiple parties, including the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. The document is specifically designed to facilitate transparent financial transactions, enable proper documentation of contract progress, and provide a formal mechanism for contractors to request compensation while simultaneously releasing any potential future claims against Pinellas County for the specified contract period.
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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
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