VOUCHER SIGNATURE REVOCATION FORM–
(SAMS PROCEDURE 17.20.70)
The Voucher 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 vouchers and on the Agency
File Balancing Report.
The Voucher 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:
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.