Sample_Application_for_Payment.pdf
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- Solicitation number
- 24-0384-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for contractor payments related to the Annual Sanitary Sewer Repair and Extension FY24-FY26 project. The form provides a standardized template for contractors to request payment, documenting the original agreement amount, change orders, retainage, and current payment due. It includes sections for tracking payment periods, change order summaries, and requires approvals from the consultant, engineering project manager, and department director.
The payment application includes a certification and waiver section where the contractor confirms that previous payments have been used to pay for materials and work performed, and releases the Pinellas County Board of County Commissioners from future claims related to the project. The form is flexible, with blank spaces to be filled in with specific project details such as payment application number, purchase order number, payment period, and specific dollar amounts. It serves as both a request for payment and a legal document acknowledging the work completed and compensation received.
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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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