Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
Reconstruct Airport Perimeter Fence Phase 1-PIE
Solicitation number
24-0809-ITB-C
Issued by
Pinellas County, Clewiston City, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractors to submit payment requests. The form provides a standardized template for documenting project financials, including sections for change order summaries, payment summaries, and formal certification of work completed and payments due. It includes fields for tracking the original agreement amount, retainage percentage, total earned work, previous payments, and current payment due.

The form serves as both an application for payment and a legal release, where the contractor certifies that previous payments have been used to cover materials and work performed, and releases the Board of County Commissioners from future claims related to the specific contract period. Approval requires signatures from multiple parties, including the consultant or design professional, the Pinellas County Engineering Project Manager, and the department director, ensuring multiple levels of review and accountability for the payment request.

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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 .