Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY 2026 Pavement Preservation Package 1
- Solicitation number
- 25-0070-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractors to request payment for work completed on a project. The form provides a structured template for documenting payment details, including change orders, payment periods, original agreement amounts, retainage percentages, and current payment due. The form is intended to be used for the FY 2026 Pavement Preservation Package 1, which involves milling and resurfacing approximately 34.98 lane miles of roadway across five paving locations within Pinellas County, Florida, including one arterial and four local neighborhood projects.
The payment application includes sections for tracking financial transactions, with spaces to record change order summaries, payment summaries, and certifications. The document requires signatures from the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. By completing this form, the contractor releases and waives all claims against the Pinellas County Board of County Commissioners related to the performance of the agreement for the specified payment period. The form serves as both an application for payment and a legal document acknowledging the completion of work and the use of previous payments for project obligations.
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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 .