CONTRACT SIGNATURE REVOCATION FORM–
AGENCY HEAD
(SAMS PROCEDURE 15.20.96)
The Contract Signature Revocation Form – Agency Head form is used to revoke specimen signatures for the previous Agency
Head and all associated designees authorized to sign the Agency Head approval line on contracts, interagency agreements, purchase
orders, grants and leases.
Contract Signature Revocation Form – Agency Head
forms must be emailed with the agency number included in the subject
line and the name of the revoked 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 revocation form):
Name (Type/Print): ____________________________________________________________________________
Phone Number: ______________________________________________________________________________
Email Address: ______________________________________________________________________________
4) NAME OF PREVIOUS AGENCY HEAD (Type/Print the name of the previous Agency Head):
___________________________________________________________________________________________
5) EFFECTIVE DATE OF REVOCATION*: __________________________________________________________
6) By signing this form, I am requesting that the Comptroller’s Office revoke signature authority for the above-named
Agency Head and all associated designees on the effective date shown above. I hereby certify that the original signed
document exists in my possession.
____________________________________________ ______________________________________________
Signature of Authorized Representative Type/Print Name of Authorized Representative
____________________________________________ ______________________________________________
Type/Print Title of Authorized Representative
*Enter the date the revocation is effective. Do not enter the current date unless it is the effective date for this revocation.
SCO-470-B 9/2019-000
