CONTRACT SIGNATURE REVOCATION FORM–
DESIGNEE
(SAMS PROCEDURE 15.20.96)
The Contract Signature Revocation Form - Designee form is used to revoke specimen signatures for persons authorized to sign
the Agency Head approval line on contracts, interagency agreements, purchase orders, grants and leases.
Contract Signature Revocation Form - Designee 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 PERSON PREVIOUSLY AUTHORIZED TO SIGN OR AFFIX THE AGENCY HEAD SIGNATURE
(Type/Print the name of the individual previously authorized to sign or affix the signature of the 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 signature designee 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-A 9/2019
