CONTRACT SIGNATURE AUTHORIZATION FORM
(SAMS PROCEDURE 15.20.95)
The Contract Signature Authorization Form is used to provide specimen signatures to the Comptroller for persons authorized to
sign the Agency Head approval line on contracts, interagency agreements, purchase orders, grants and leases.
Contract Signature Authorization Forms must be emailed with the agency number included in the subject line and the
name of the authorized individual in the body of the email to:
obligations@illinoiscomptroller.gov
The original signed document must be maintained by the Agency.
Each form must be scanned as a separate document.
Multiple forms can be sent in one email.
ALL FIELDS ARE REQUIRED
1) AGENCY NAME (Do Not Abbreviate): _________________________________________________________________
2) AGENCY CODE (Three-digit Number): ______ ______ ______
3) AGENCY CONTACT INFORMATION (The individual to be contacted regarding this signature authorization form):
Name (Type/Print): ____________________________________________________________________________
Phone Number: ______________________________________________________________________________
Email Address: ______________________________________________________________________________
4) NAME OF AGENCY HEAD OR DESIGNEE (Type/Print the name of either the Agency Head or designee authorized to
sign or affix the signature of the Agency Head):
______________________________________________________________________________________________
5) SPECIMEN SIGNATURE (The designee must sign [not print]/affix the Agency Head’s name followed by his/her name
precisely as it will appear on the contract–initials are not acceptable):
________________________________________________________________________________________________
6) EFFECTIVE DATE OF AUTHORIZATION*: ____________________________________________________________
7) APPROVAL (Type/Print the title and agency name into the certification):
I certify that I am the elected/appointed ____________________________________________________________ of the
________________________________________________________________________________________________
I hereby approve the signature delegation authorized above for the purposes of signing contracts and/or associated
affidavits. I hereby certify that the original signed document exists in my possession.
8) ____________________________________________ ______________________________________________
Signature of Agency Head Type/Print Name of Agency Head
*Enter the effective date authorization is granted. Do not enter the current date unless it is the effective date for this authorization.
SCO-470 9/2019
(Title of Agency Head)
(Name of Agency)
n
Agency Head signature is a stamp.
