Authorized Signature Form

					                                                               AUTHORIZED SIGNATURE FORM

Department________________________________________                                                        Effective Date_________________________
Department #____________________________
Date________________________________

The following employees are hereby authorized to sign/initial (in ink), on my behalf, all documents, payrolls, payroll documents and accounting transaction
documents pertaining to those funds which are listed below by account number.


          GAX’s/TA’s/TP’s/PRC’s/MD’s                                                                                  IET’s/PRCI’s/JV’s/CR2’s/CDE’s/CDR’s
           EXTERNAL DOCUMENTS                                 PAYROLLS & PAYROLL DOCUMENTS                                   INTERNAL DOCUMENTS


Signature_________________________________             Signature_________________________________              Signature_________________________________

Name (type)_______________________________             Name (type)_______________________________              Name (type)_______________________________

Signature_________________________________             Signature_________________________________              Signature_________________________________

Name (type)_______________________________             Name (type)_______________________________              Name (type)_______________________________

Signature_________________________________             Signature_________________________________              Signature_________________________________

Name (type)_______________________________             Name (type)_______________________________              Name (type)_______________________________

Signature_________________________________             Signature_________________________________              Signature_________________________________

Name (type)_______________________________             Name (type)_______________________________              Name (type)_______________________________

Fund               Department                 Unit     Fund               Department                   Unit    Fund               Department                   Unit

_________________________________________              _________________________________________               _________________________________________


APPROVED BY DEPARTMENT HEAD_____________________________________________________                                             Send one (1) original and
                                                                                                                                 one (1) copy to:

DEPARTMENT HEAD (type)_____________________________________________________________                                    Department of Administrative Services
                                                                                                                           State Accounting Enterprise
                                                                                                                                  Daily Processing
                                                                                                                               rd
Note: The Department Head is the only employee authorized to sign an appropriation transfer                                   3 Fl, Hoover Building
                                                                                                                              Des Moines, IA 50319

				
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