Sample_Application_for_Payment.pdf
PDF 75 KB Posted
- Attached to
- Pave Strawberry Parking Lot (PID 004570A) - St. Pete-Clearwater International Airport STEP 2
- Solicitation number
- 23-0593-ITB-C STEP 2
- 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 use in contract payment processing. The form provides a standardized template for contractors to submit payment requests, documenting project financial details including original agreement amounts, change orders, retainage percentages, and current payment due. The form requires signatures and approvals 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 document, where the contractor certifies that previous payments have been used to pay for materials and work performed, and releases the Board of County Commissioners from future claims related to the specific project period. While the form is a generic template, it is specifically associated with the Strawberry Parking Lot reconstruction project at St. Pete-Clearwater International Airport, which involves reconstructing and expanding parking facilities, including surveys, clearing, pavement work, drainage improvements, utilities installation, lighting, signage, and related infrastructure enhancements.
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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 .