VOUCHER SIGNATURE REVOCATION FORM–
DESIGNEE
(SAMS PROCEDURE 17.20.70)
The Voucher Signature Revocation Form - Designee form is used to revoke specimen signatures for persons authorized
to sign the Agency Head approval line on vouchers and the Agency File Balancing Report.
Voucher 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:
vouchercontrol@illinoiscomptroller.gov
The original signed document must be maintained by the Agency.
Each form must be scanned as a seperate 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 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-095-A 9/2019
