Sample_Application_for_Payment.pdf

75 KB Posted

Attached to
WELL SERVICES FOR PINELLAS COUNTY UTILITIES
Solicitation number
23-0884-ITB-C
Issued by
Pinellas County, Florida

About this file

Written by GovTribe AI ·

This document is a sample Application and Certificate for Payment form for Pinellas County, designed for use in contract payment processes. The form provides a standardized template for contractors to request payment, documenting project-specific financial details such as original agreement amount, change orders, retainage, and current payment due. The form includes sections for tracking payment periods, change order summaries, and requires signatures from the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director.

The payment application serves as both a financial request and a legal release, with the contractor certifying that previous payments have been used to pay obligations for materials and work performed. The form includes a comprehensive waiver where the contractor releases Pinellas County from all potential claims, demands, damages, and expenses related to the project. While no specific dollar amounts are filled in on this sample form, it provides a standardized mechanism for documenting and processing contract payments within Pinellas County's procurement and project management system.

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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 .