Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- STAR Center Chiller 2 Replacement
- Solicitation number
- 23-1128-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, designed for contractors to request payment for work completed on a specific project. The form provides a structured template for documenting change orders, payment summaries, and releasing claims, with designated spaces for the contractor, payment period, purchase order number, and various approvals from the Consultant, Engineering Project Manager, and Department Director.
The form includes sections for tracking the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It serves as both an application for payment and a legal release, where the contractor certifies that previous payments have been used to pay obligations for materials and work performed, and waives all claims against the Pinellas County Board of County Commissioners related to the project's performance. The document is designed to provide a standardized, transparent process for contractors to request and receive payment for work completed on county projects.
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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
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