SIGNATURE AUTHORIZATION FORM - Excel by an1SdU4

VIEWS: 21 PAGES: 1

									                                         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                                                FFY 2012

 OFFICIAL NAME OF ORGANIZATION/INSTITUTION
                                                                                      AGREEMENT #

 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. This authorization shall remain in effect until revoked in writing or superseded by an updated
Signature Authorization form. The most recently submitted Signature Authorization Form shall be the only authorization in

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.



              Authorized to sign claims


                    Name and Title                                                            Signature


              Authorized to sign claims


                    Name and Title                                                            Signature


              Authorized to sign claims


                    Name and Title                                                            Signature


              Authorized to sign claims


                    Name and 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 and TITLE OF ADMINISTRATOR, BOARD CHAIR                                                        SIGNATURE
OR PERSON WITH LEGAL FINANCIAL RESPONSIBILITY

                                                                                                      DATE

								
To top