Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- U. S. 19 Fuel Site Renovation
- Solicitation number
- 23-1167-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request payment for work completed on a specific project. The form provides a structured template for documenting payment details, including change orders, original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The form requires signatures and approvals from the contractor, a consultant or design professional, a Pinellas County engineering project manager, and the department director.
The application serves as both a payment request and a legal release, where the contractor certifies that previous payments have been used to pay for materials and work performed, and waives all current and future claims against Pinellas County related to the project's performance. While specific financial details are left blank on this sample form, it is part of the documentation for the U.S. 19 Fuel Site Renovation project, which involves closing an existing fueling system and installing new aboveground fuel tanks, piping, dispensers, and a canopy. The form provides a standardized method for contractors to request periodic payments and formally document the financial progression of the project.
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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
File details come from the government source that posted it. Updated .