Snohomish County Human Services 3/6/2018

Signature Authorization Form Instructions PURPOSE The Signature Authorization Form identifies the person(s) who has the authority to sign contracts, amendments and invoices/requests for reimbursement. The form also designates the email address for the authorized recipient(s) of contracts and amendments from the Human Services Department. It is important that the signatures on file with the Department are current. Whenever there is a change in an authorized signor, a new Signature Authorization Form must be completed. The new form supersedes the previous form. Additional forms may be requested by sending an email to HSD.Contracts@snoco.orq or by contacting your program manager. INSTRUCTIONS Please print the Signature Authorization Form on white paper. Complete each section where indicated and sign in blue ink. Make a copy of the form for your records and return the signed original form to the address below. Electronic or photocopied forms are not accepted. Snohomish County Human Services Attn: HSD Contracts 3000 Rockefeller Avenue, M/S 305 Everett, WA 98201 SECTION 1: Official Business Name of Organization Complete organization name, mailing address and date form is submitted. SECTION 2: Authorizing Authority This section is to be completed by the person(s) who has the authority to authorize the person(s) entered in Section 3 and Section 4 to represent your organization for these actions. Usually this person(s) will be the board president, chair, director, CEO or other person(s) delegated by the ruling body of the organization to act on its behalf. SECTION 3: Authorization to Sign Contracts/Contract Amendments Complete this section with the name of the person(s) authorized by your organization and/or board of directors to sign contracts and contract amendments for all programs. SECTION 4: Authorization to Sign Invoices / Requests for Reimbursements Complete this section with the name of the person(s) authorized by your organization and/or board of directors to sign invoices requesting reimbursement of costs and services from the Snohomish County Human Services Department for all programs. SECTION 5: Contract Delivery Designation Complete this section with the name, title and email address of the person(s) who should receive (via email) contracts for your organization. Note: The Signature Authorization Form is not write-protected. Add additional lines to any section if needed. Be sure to include all of the appropriate signors to cover all contracts with the Human Services Department. Rev.11/7/17