Sample_Application_for_Payment.pdf

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Attached to
Lake Seminole Restoration Site Irrigation Line Installation - ARPA
Solicitation number
24-0087-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, Florida, designed to facilitate contractor payment processing for county projects. The form provides a standardized template for documenting payment requests, change orders, and financial reconciliation for construction or service contracts, with sections for tracking original agreement amounts, retainage percentages, previous payments, and current payment due.

The application serves as both a payment request and a legal release document, wherein the contractor certifies that previous payments have been used to cover materials and work performed, and releases the Board of County Commissioners from future claims related to the specific contract period. The form requires signatures and approvals from multiple parties, including the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director, ensuring multiple levels of financial and contractual verification before payment is processed.

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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 .