16A Form MRC Revised: 09/24/2017
STATE OF MINNESOTA
MINNESOTA STATE
16A.15 Form
(Based on Minnesota Statute §16A.15)
College/University/System Office:
Division/Department:
Vendor/Contractor Name and Number:
INSTRUCTIONS: Submit one original and two photocopies when processing the contract/purchase order.
I. NO OBLIGATION INCURRED PRIOR TO ENCUMBRANCE OR CONTRACT EXECUTION
(Minnesota Statute §16A.15, Subd. 3)
I certify work has not started as of and will not begin until this contract is fully executed.
Signature of Person Responsible: Date:
II. OBLIGATION INCURRED PRIOR TO ENCUMBRANCE
(Minnesota Statute §16A.15, Subd. 3)
Total Amount Not Encumbered: $ Obligation Date: (when work started)
Reason why obligation was incurred prior to funds being encumbered and contract being executed:
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What corrective action will be taken to prevent violation of M.S. §16A.15, Subd. 3, from occurring in the future?
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Signature of Person Responsible: Date:
Date:
Signature of Supervisor*:
Signature of Provost:
Date:
*as stated in Delegation of Authority Letter
Mesabi Range College Threshold = $300.00
