Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
Pave Strawberry Parking Lot (PID 004570A)
Solicitation number
24-0116-ITB-C
Issued by
Pinellas County, Clewiston City, Florida

About this file

Written by GovTribe AI ·

The document is a Sample Application for Payment form from Pinellas County, designed for contractors to request payment for work completed on a specific project. The form provides a structured template for documenting payment details, including a change order summary, payment summary, and certification of payment compliance. It includes sections for the contractor to list the payment period, original agreement amount, retainage percentage, total earned less retainage, and current payment due.

The form serves as both an application for payment and a legal release, wherein 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 project. The document requires signatures and approvals from multiple parties, including the consultant or design professional, the county engineering project manager, and the department director. While specific to the Strawberry Parking Lot project at St. Pete-Clearwater International Airport, this form represents a standard payment processing document used in local government construction and infrastructure 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 .