CASL_Sole-Proprietor-PKGDOC1534042-0006.pdf
PDF 147 KB Posted
- Attached to
- Podiatry Services RFR
- Solicitation number
- BD-26-1053-1053C-CSR-120507
- Issued by
- Hampden County, Massachusetts
About this file
This document is a Contractor Authorized Signatory Form issued jointly by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) for the Commonwealth of Massachusetts. The form is designed for individual contractors, sole-proprietors, or single-member LLCs to provide a notarized signature of the authorized person who can sign contracts and legally binding documents on behalf of the contractor.
The form emphasizes privacy protection, instructing contractors not to attach documents containing personal identifying information. It provides a template for capturing the contractor's legal name, vendor/customer code, signatory's full legal name and title, and includes a notary public acknowledgement section. The document requires completion in the presence of a notary, who will verify the signatory's identity and witness the signature. A copy of this form must be attached to the record copy of the contract filed with the department, and the Commonwealth reserves the right to publish the names and titles of authorized signatories.
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Text version
Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY
FORM
This form is jointly issued and published by the Office of the Comptroller (CTR) and the Operational Services Division (OSD) as the default form for all Commonwealth Departments when another form is not prescribed by regulation or policy.
Notarized Signature for Individual, Sole-Proprietor or Single Member LLC (must match Form W-9 tax classification)
INSTRUCTIONS: Any Contractor, sole-proprietor, or an individual, must provide a notarized signature of the authorized person who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf.
For privacy purposes DO NOT ATTACH any documentation containing personal information, such as bank account numbers, social security numbers, driver’s licenses, home addresses, social security cards or any other personally identifiable information that you do not want released as part of a public record. The Commonwealth reserves the right to publish the names and titles of authorized signatories of contractors.
AFFIX NOTARY SEAL/STAMP
A copy of this document must be attached to the “record copy” of a contract filed with the department.
Certificate of Acknowledgement of Notary Public Before me, the undersigned notary public, the above named individual proved to me through satisfactory evidence of identification, to be the person whose name is signed above and acknowledged to me that (he)/(she) signed for its stated purpose.
Print Notary Name Notary Signature (ink on paper)
Date My commission expires on
Signature (ink on paper) Contractor Signature as it will appear on contract or other documents (Complete only in presence of notary)
Print Signatory’s full legal name Title
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number)
File details come from the government source that posted it. Updated .