Sample_Application_for_Payment.pdf

PDF 75 KB Posted

Attached to
Pave Strawberry Parking Lot (PID 004570A) - St. Pete-Clearwater International Airport
Solicitation number
23-0593-ITB-C
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 contractor payment processing related to county projects. The form provides a template for contractors to submit payment requests, detailing change orders, payment summaries, and formal certification of work completed and payments due. The form includes sections for tracking original agreement amounts, retainage percentages, total earned amounts, previous payments, and current payment due.

The payment application serves as both a financial record and a legal release document, wherein 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 contract period. The form requires approvals from multiple parties, including a Consultant or Design Professional/Engineer of Record, a Pinellas County Engineering Project Manager, and the department director, ensuring multi-level verification of the payment request's accuracy and legitimacy.

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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 .