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75.45.01.fo 75.45.01.FO Authorized OSPA Signatures

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AUTHORIZED OSPA SIGNATURES
This form establishes permission for the individuals named to request off-cycle
manual checks and pay advances from OSPS.
For OSPS Use Only
Database Updated
Existing Signatures Verified
Hand-written Info? Yes No
If Yes, email verification rec’d on: ________
Initials
Retired and moved to Inactive tab on: (Retention: 6 years)
OREGON STATEWIDE
PAYROLL SERVICES /
PAYROLL SYSTEM SUPPORT
Fax: (503) 378-3518
Email: OSPS.Help@oregon.gov
INSTRUCTIONS:
1. COMPLETE ONLINE ONLY.
2. For each signer, select and
replace the “Not Used”
with a name.
3. Choose the authority
level(s) for each name.
4. Complete the agency
authorization info.
5. Print form and collect
signatures.
6. Return ORIGINAL form to
OSPS.
If you need immediate
approval, you may fax the
form to OSPS; we will honor
the fax for three days while
the original is in transit.
Annual Review Response
Date /
Initial
No Changes
/
No Changes
/
No Changes
/
No Changes
/
No Changes
/
Revised 08/2015
Form No. 75.45.01.FO
Section A: Authorized Signers (use additional pages as needed; check box below list)
I certify: Payroll Advances will comply with OAM Policy 45.25.00.PO, applicable collective
bargaining agreement, and/or agency policy as appropriate.
Printed Name
Signature
Authority
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
Manual Checks
Pay Advances
CHECK ONE: This is the only page This is Page _____ of _____.
Hand-written information will be verified by OSPS through the person listed in Section B.
Section B: Administrator Authorization and Alternate Designee
NOTE: Nobody in this section can be listed in Section A as an authorized signer.
I authorize the individuals listed in Section A to submit check requests to OSPS on behalf of:
Agency Number(s):
Administrator Printed Name
Signature
Date
Future updates may be authorized by (optional alternate designee):
Alternate Designee Printed Name
Signature
Admin Initials
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
NOT USED
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75.45.01.fo 75.45.01.FO Authorized OSPA Signatures

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Completed 10 July 2020

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