Sample_Application_for_Payment.pdf

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Attached to
Sanitary Sewer Pump Station Repair, Rehabilitation, and Improvement Contract for Fiscal Years 2025-2028 (PID 000964A)
Solicitation number
24-0073-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 for contractors to submit payment requests for projects. The form provides a structured template for documenting payment details, including change orders, original agreement amounts, retainage percentages, and current payment due. It serves as both an application for payment and a release of claims, allowing the contractor to certify that previous payments have been used to pay for materials and work performed in conjunction with the project.

The form includes sections for tracking financial details such as original agreement amount, retainage, total earned less retainage, and previous payments. It requires approval signatures from the consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. By completing this form, the contractor releases and waives all claims against the Pinellas County Board of County Commissioners for the specified payment period, effectively documenting the financial progress and settlement of work completed under the contract.

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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 .