Sample_Application_for_Payment.pdf

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Attached to
County Wide Parks and Conservation Resources (PCR) Roof Replacement Contract STEP 2
Solicitation number
23-0653-ITB-C STEP 2
Issued by
Pinellas County, Clewiston City, Florida

About this file

Written by GovTribe AI ·

This document is a Sample Application for Payment form for Pinellas County, specifically designed for documenting contract payment details and progress. The form provides a standardized template for contractors to request payment, track change orders, and certify work completed during a specific payment period. The application includes sections for capturing payment application number, purchase order number, payment period, change order summary, and a comprehensive payment summary.

The form requires detailed financial documentation, including the original agreement amount, retainage percentage, total earned less retainage, previous payments, and current payment due. It also includes a certification section where the contractor affirms that previous payments have been used to pay for materials and work performed, and provides a legal release of claims against Pinellas County for the specified contract period. The document is intended to provide a clear, structured method for contractors to request payment and document project financial progress within Pinellas County's contractual framework.

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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 .