Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- WTE Structural Steel Replacement
- Solicitation number
- 23-1161-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, specifically designed for contractors to request payment for work performed on a project. The form provides a structured template for documenting payment details, including change order summaries, payment periods, original agreement amounts, retainage percentages, and current payment due. It includes sections for the contractor to certify that previous payments have been used to pay for materials and work, and includes spaces for approval by a consultant, design professional, engineering project manager, and department director.
The form serves as both an application for payment and a waiver of claims, with the contractor releasing Pinellas County from any current or future claims related to the project's performance. While the specific project details are not filled in on this sample form, it is associated with the Waste-to-Energy (WTE) Structural Steel Replacement project, which involves critical infrastructure improvements at the Pinellas County Waste-to-Energy Facility. The form is designed to facilitate transparent and documented payment processes for contractors working on county projects, ensuring proper tracking of project expenses and progress.
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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 .