VOUCHER SIGNATURE AUTHORIZATION FORM
(SAMS PROCEDURE 17.20.65)
The Voucher Signature Authorization Form is used to provide specimen signatures to the Comptroller for persons authorized to
sign the Agency Head approval line on vouchers and the Agency File Balancing Report. Submission of new or revised Signature
Authorization Forms is dependent on when the use of the Agency Head signature is authorized or revised.
Voucher 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:
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 voucher–initials are not acceptable):
6) VOUCHERS AUTHORIZED TO SIGN (Place an “X” on the appropriate line(s) indicating which vouchers the individual is
authorized to sign):
_____ Payroll/Contractual Payroll/Retirement
_____ Other (For Payroll purposes only) Please specify: ______________________________________________
7) EFFECTIVE DATE OF AUTHORIZATION
8) APPROVAL (Type/Print the title and agency name into the certification):
I certify that I am the elected/appointed __________________________________________________ of the
_____________________________________________ designated by Section 10 of “an Act in relation to State Finance”
as the officer responsible for certifying and approving vouchers for this Agency. I hereby approve the signature delegation
authorized by this form. I hereby certify that the original signed document exists in my possession.
9) ____________________________________________ ______________________________________________
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.
(Title of Agency Head)
(Name of Agency)
Agency Head signature is a stamp.