Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY2024-2026 COUNTYWIDE PAVEMENT PRESERVATION
- Solicitation number
- 23-0496-ITB-C
- Issued by
- Pinellas County, Clewiston City, Florida
About this file
This document is a Sample Application for Payment form from Pinellas County, designed for use in county contract payment processes, specifically related to the FY2024-2026 Countywide Pavement Preservation program. The form provides a template for contractors to request payment, documenting project progress, financial details, and serving as a release of claims for work performed during a specific payment period.
The payment application includes sections for tracking change orders, recording the original agreement amount, calculating retainage, documenting previous payments, and determining the current payment due. The form requires signatures from the contractor, a consultant or design professional, the Pinellas County Engineering Project Manager, and the department director. By completing this form, the contractor certifies that previous payments have been used to pay for materials and work, and releases the county from future claims related to the specific contract period.
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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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