Sample_Application_for_Payment.pdf

PDF 75 KB Posted

Attached to
Repairs, Electric - Industrial Equipment (Utilities)
Solicitation number
25-0328-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, Florida, specifically designed for contractors to request payment for work performed on a county project. The form provides a structured template for documenting payment details, including change orders, payment summaries, and certification of work completed. It includes sections for tracking the original agreement amount, retainage percentages, total earned amount, previous payments, and the current payment due.

The application serves as both a payment request and a legal release, where the contractor certifies that previous payments have been used to pay for materials and work performed, and releases Pinellas County from any further claims related to the specific project period. The form requires approval from multiple parties, including a consultant or design professional, the county engineering project manager, and the department director, ensuring multiple levels of verification before payment is processed.

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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 .