Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
FY 2024 Pavement Preservation Package 3
Solicitation number
23-0833-ITB-C
Issued by
Pinellas County, Florida

About this file

Written by GovTribe AI ·

The document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for documenting contract payment processes and requirements. The form provides a standardized template for contractors to submit payment requests, detailing change orders, payment summaries, and certification of work completed. It includes sections for tracking original agreement amounts, retainage percentages, total earned amounts, previous payments, and current payment due, with designated approval lines for the consultant, project manager, and department director.

The form serves as both a payment application and a legal release document, 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 specific contract period. While no specific dollar amounts are filled in on this sample form, it is clearly associated with the FY 2024 Pavement Preservation Package 3, which involves approximately 36.05 miles of roadway improvements across one arterial and three local neighborhood projects within Pinellas County, Florida.

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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 .