Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Dunn Exploratory Well (PID 004365A)
- Solicitation number
- 23-1141-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, Florida, designed for contractors to request compensation for work performed on a specific project. The form provides a structured template for documenting payment details, including a change order summary, payment summary, and certification of work completed. The form requires entries for payment application number, purchase order number, payment period, original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due.
The form includes sections for approval by a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. It also contains a release and waiver clause where the contractor acknowledges that the payment requested is in accordance with the agreement terms and releases the Board of County Commissioners from future claims related to the specific work period. The document is meant to provide a standardized method for contractors to request payment and document the financial progress of a project, with spaces for detailed financial tracking and official approvals.
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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 .