SIGNATURE AUTHORIZATION NSLP

							                                        STATE OF HAWAII
                                    DEPARTMENT OF EDUCATION                                      CHILD NUTRITION PROGRAMS
                          Office of Hawaii Child Nutrition Programs
                                     650 IWILEI ROAD, SUITE 270                        SIGNATURE AUTHORIZATION FOR CLAIMS
                                        HONOLULU, HI 96817

 OFFICIAL NAME OF ORGANIZATION/INSTITUTION                                            AGREEMENT #                  DUNS #


 DBA (Doing Business As, Trade Name, if applicable)                                   CONTACT PERSON


 ADDRESS                                                                              CONTACT TITLE


 EMAIL ADDRESS                                                                        PHONE


SIGNATURE AUTHORIZATION
For Submission of Claims for Reimbursement
Claims submitted for reimbursement are not valid unless they have been properly signed by authorized representatives of the
institution. Claims submitted without duly authorized signatures will NOT be paid. Accordingly, you must ensure that this
Signature Authorization form is submitted to the Office of Hawaii Child Nutrition Programs whenever there is a change in staff
which affects this authorization.

The following individuals are authorized to sign and submit Claims for Reimbursement (claims). At all times, the claims shall
contain signatures by two different parties to ensure a second-party review of claims. This authorization shall remain in effect
until revoked or superseded in writing.


 Authorized to sign claims for programs checked:                      NSLP Only                   FFVP Only                    Both


                     Name / Title                                                             Signature


 Authorized to sign claims for programs checked:                      NSLP Only                   FFVP Only                    Both


                     Name / Title                                                             Signature


 Authorized to sign claims for programs checked:                      NSLP Only                   FFVP Only                    Both


                     Name / Title                                                             Signature


 Authorized to sign claims for programs checked:                      NSLP Only                   FFVP Only                    Both


                     Name / Title                                                             Signature

I CERTIFY THAT THE ABOVE INDIVIDUALS ARE AUTHORIZED TO SIGN CLAIMS ON BEHALF OF OUR ORGANIZATION. I UNDERSTAND THAT THIS AUTHORIZATION
SHALL REMAIN IN EFFECT UNTIL REVOKED OR SUPERSEDED IN WRITING. I WILL NOTIFY OHCNP PROMPTLY OF ANY CHANGES TO THE ABOVE. I CERTIFY THAT I
HAVE RETAINED A COPY OF THIS AUTHORIZATION FOR OUR FILES.




NAME/TITLE OF ADMINISTRATOR, BOARD CHAIR                                                            SIGNATURE
OR PERSON WITH LEGAL FINANCIAL RESPONSIBILITY

                                                                                                      DATE