Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- FY2025-2027 Countywide Pavement Preservation
- Solicitation number
- 25-0112-ITB-C
- Issued by
- Pinellas County, Florida
About this file
This document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for use in the Countywide Pavement Preservation program. The form provides a standardized template for contractors to request payment for work completed, with sections for recording payment application details, change order summaries, and payment summaries. It includes spaces for the contractor to certify that previous payments have been used to pay for materials and work, and includes release and waiver language for claims against Pinellas County.
The application form includes key financial tracking elements such as the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. The document requires approval signatures from multiple parties, including a Consultant or Design Professional/Engineer of Record, the Pinellas County Engineering Project Manager, and the Director of the relevant department. The form is part of the administrative process for the FY2025-2027 Pavement Preservation program, which aims to improve roadway conditions through milling, resurfacing, and potential road base reconstruction across 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
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