Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY 2026 Pavement Preservation Package 2
- Solicitation number
- 25-0071-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, 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, original agreement amount, retainage, previous payments, and current payment due. It includes sections for the contractor to certify that payments have been used to pay obligations for materials and work performed, and includes spaces for approvals from a consultant, engineering project manager, and department director.
The form serves as both an application for payment and a release of claims, where the contractor waives all current and future claims against Pinellas County related to the performance of the agreement. While specifically tied to the FY 2026 Pavement Preservation Package 2 project involving approximately 44.26 lane miles of roadway improvements, this document is a standardized payment request form that can be used across different county projects. The form includes provisions for tracking changes to the original agreement amount through change orders and provides a mechanism for progressive payments throughout the project's duration.
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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 .