Sample_Application_for_Payment.pdf
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- Solicitation number
- 23-1234-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, designed to be used for documenting contract payment details. The form provides a standardized template for contractors to request payment for work completed, with sections for tracking change orders, payment summaries, and formal certification of payment requests. The form includes spaces for critical financial information such as the original agreement amount, retainage percentage, total earned amount, previous payments, and current payment due.
The payment application serves as both a financial request and a legal release document, where the contractor certifies that previous payments have been used to pay for materials and work performed, and releases Pinellas County from future claims related to the specific payment period. The form requires approval signatures from multiple parties, including a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director, ensuring multi-level verification of the payment request. While the form is a template, it is specifically associated with the Stormwater Starkey Facility M10 Modification project, which is funded through Penny for Pinellas, SWFWMD, and ARPA sources.
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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
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