Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- MAINTENANCE AND MINOR REPAIRS OF FIXED CONCRETE BRIDGE STRUCTURES, PEDESTRIAN BRIDGES, AND BOX CULVERTS
- Solicitation number
- 23-0811-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 county projects. The form provides a standardized template for documenting payment details, including sections for change order summaries, payment summaries, and certifications of work completed. It allows contractors to record the original agreement amount, calculate retainage, track previous payments, and specify the current payment due.
The form includes spaces for various approvals, including verification 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 receipt of payment and releases the county from further claims related to the specific work period. This document appears to be part of the county's standard financial documentation process for managing contracts, specifically related to the maintenance and minor repairs of fixed concrete bridge structures, pedestrian bridges, and box culverts throughout unincorporated Pinellas County.
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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 .