Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
Pinellas County Jail Elevator Modernization - Detention Central Intake Building
Solicitation number
24-0301-ITB-C
Issued by
Pinellas County, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractor payment requests related to the Jail Elevator Modernization project. The form provides a standardized template for contractors to document payment applications, including sections for change order summaries, payment summaries, and certifications of work performed. The form allows for tracking of original agreement amounts, retainage percentages, total earned amounts, previous payments, and current payment due.

The payment application form includes provisions for the contractor to certify that previous payments have been used to pay obligations for materials and work performed, and includes a comprehensive release and waiver of claims against Pinellas County for the specified payment period. The document requires signatures and approvals from multiple parties, including the consultant or design professional, the Pinellas County Engineering Project Manager, and the department director, ensuring a multi-step verification process for contractor payments.

View the file

Other files

File Type Posted
Pinellas_County_Jail_Elevator_Modernization_-_Detention_Central_Intake_Building.pdf PDF
22172_Pinellas_County_Jail_Lobby_Elevator_Mod_Spec_REV_B_FINAL_2.26.24.pdf PDF
22172_Pinellas_County_Jail_Lobby_Elevator_Mod_Spec_REV_FINAL_12.19.23.pdf PDF
Affdavit_of_Release_and_Guarantee.pdf PDF
Sample_Agreement-24-0301.pdf PDF
Pricing_ProposalITB24-0301(reference_only).pdf PDF
Performance_and_Payment_Bonds.pdf PDF
QUALIFICATION_SUBMITTAL_FORM_Non_FDOT.pdf PDF
Bid_Submittal_Form-JOC.pdf PDF
Sample_Change_Order.pdf PDF
2023-10-20_Arch_(Permit)_Central_Intake_-_Elevator_Modernization.pdf PDF
OpenGov_Fillable-_Final.pdf PDF
2023-10-20_Elec_(Permit)_Central_Intake_-_Elevator_Modernization.pdf PDF
Airport_Security_Program.pdf PDF
E-Verify_Affidavit.pdf PDF
Florida_Trench_Safety_Form.pdf PDF
Show all 16

On GovTribe

Work with this file

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 .