Sample_Application_for_Payment.pdf
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- Solicitation number
- 24-0722-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
The document is a Sample Application for Payment form for Pinellas County Department, designed to facilitate contractor payment processing for a specific project. The form provides a structured template for documenting payment details, including sections for change order summaries, payment summaries, and certification of payment requirements. It includes fields for tracking the original agreement amount, retainage percentage, total earned amounts, previous payments, and current payment due.
The form serves as a comprehensive payment request and release document, requiring signatures and approvals from multiple parties including the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. By completing this form, the contractor certifies that previous payments have been used to pay for materials and work performed, and releases the County from any further claims related to the specific performance period covered by the payment application.
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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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