Sample_Application_for_Payment.pdf
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- Solicitation number
- 24-0791-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 use in the 53rd Avenue N. Force Main Replacement project (PID 005582A). The form provides a standardized template for contractors to request payment, detailing the project's financial progress, including original agreement amounts, change orders, retainage, and current payment due. It serves as both an application for payment and a release of claims document, allowing the contractor to certify work completed and request compensation while simultaneously waiving future claims against Pinellas County for the specified work period.
The payment application includes sections for tracking change orders, documenting the original agreement amount, calculating retainage, and determining the current payment due. The form requires approval from multiple parties, including the consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. By completing this document, the contractor acknowledges that previous payments have been used to pay for materials and work performed, and releases Pinellas County from potential future claims related to the project's performance during the specified payment 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
File details come from the government source that posted it. Updated .