Sample_Application_for_Payment.pdf
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- Solicitation number
- 24-0692-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, designed for contractors to submit payment requests for project work. The form provides a structured template for documenting payment details, including change orders, original agreement amounts, retainage percentages, and current payment due. The form is specifically related to the ARPA Stormwater Starkey Facility M10 Modification project, which involves retrofitting and enhancing an existing stormwater management facility to improve water quality treatment and maintain flood protection.
The payment application includes sections for tracking financial aspects of the project, such as change order summaries, payment summaries, and certifications. The form requires the contractor to certify that previous payments have been used to pay for materials and work performed, and includes a release of claims against Pinellas County. Approval signatures are required from the consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. The form is part of the standard documentation process for tracking and approving contractor payments for the stormwater facility modification project.
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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
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