Sample_Application_for_Payment.pdf

75 KB Posted

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

About this file

Written by GovTribe AI ·

The document is a Sample Application for Payment form for Pinellas County, Florida, specifically designed for contractors to request payment for work completed on a project. The form provides a structured template for documenting payment details, including change orders, original agreement amount, retainage, previous payments, and current payment due. It is intended to be used for tracking and approving payments for county projects, with spaces for approvals from a consultant or design professional, an engineering project manager, and a department director.

The form includes a certification section where the contractor affirms that the payment request is in accordance with the agreement terms and that previous payments have been used to pay for materials and work performed. The document also contains a waiver and release of claims section, where the contractor releases Pinellas County and its Board of County Commissioners from any potential claims related to the project for the specified payment period. This standardized form serves as a critical financial document for managing and documenting contractor payments within Pinellas County's procurement process.

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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 .