Fax Number - - E-Mail Address All routine notices relevant to the administration of the program should be sent to: Name & Title Mailing Address Telephone Number - - Fax Number - - E-Mail Address Do you currently receive payment by Automatic Deposit (ACH) for this contract? Yes No Division of Family Development Annex A Authorized Signatures List names and positions of persons authorized to sign the following and number of persons required to sign each transaction. # of Signatures Name/Address Position Required 1 2 1 Contract 3 1 Quarterly and Final 2 1 Financial Reports 3 Contract 1 Budget Modification 2 1 3 1 Checks 2 3 Other Contracts and 1 Agreements 2 3 Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board This is the address where the signed contract and all relevant legal Resolution). correspondence will be mailed. This should be the individual who signs the SLD (page
Fax Number - - E-Mail Address All routine notices relevant to the administration of the program should be sent to: Name & Title Mailing Address Telephone Number - - Fax Number - - E-Mail Address Do you currently receive payment by Automatic Deposit (ACH) for this contract? Yes No Division of Family Development Annex A Authorized Signatures List names and positions of persons authorized to sign the following and number of persons required to sign each transaction. Name/Address Position # of Signatures Required Contract 1 1 2 3 Quarterly and Final Financial Reports 1 1 2 3 Contract Budget Modification 1 1 2 3 Checks 1 2 3 Other Contracts and Agreements 1 2 3 Note 1 - Enter Authorized Signatory for the Contract (as authorized by Agency Bylaws or Board Resolution). This is the address where the signed contract and all relevant legal correspondence will be mailed. This should be the individual who signs the SLD (page