Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Bridge Structures-Fixed Concrete, Maintenance and Minor Repair_Structures_Pedestrian Bridges_Box Culverts
- Solicitation number
- 24-0211-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 contractors to request payment for work performed under a county contract. The form provides a structured template for documenting payment details, including change orders, original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It is associated with a contract for maintenance and minor repairs of fixed concrete bridge structures, pedestrian bridges, and box culverts throughout unincorporated Pinellas County.
The payment application form requires detailed documentation from the contractor, including certification that previous payments have been used to pay obligations for materials and work performed. The document includes sections for approvals by a Consultant or Design Professional/Engineer of Record, a Pinellas County Engineering Project Manager, and the Director of the relevant department. The form also includes a release and waiver clause, where the contractor releases Pinellas County from claims, demands, damages, and expenses related to the project for the specified payment period. This standardized form ensures proper documentation and accountability in the payment process for county infrastructure maintenance projects.
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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 .