Contractor Authorized Signatory Listing Single Member LLC Sole Proprietor~1.pdf
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- Solicitation number
- BD-26-1037-1CEN0-CENTR-123169
- Issued by
- Worcester County, Massachusetts
About this file
This is a Contractor Authorized Signatory Form jointly issued by the Commonwealth of Massachusetts Office of the Comptroller and the Operational Services Division for use by all state departments. The form is designated for individual contractors, sole proprietors, and single-member LLCs to provide notarized authorization signatures for individuals who are authorized to sign contracts and other legally binding documents on behalf of the contractor. The form requires the contractor's legal name, vendor/customer code, a notarized signature of the authorized signatory that matches the Form W-9 tax classification, the signatory's printed full legal name and title, notary public information including name, signature, and commission expiration date, and an affixed notary seal or stamp. The Commonwealth reserves the right to publish the names and titles of authorized signatories.
The form prohibits attachment of documentation containing personal information such as bank account numbers, social security numbers, driver's licenses, home addresses, or other personally identifiable information that would become part of the public record. A copy of the completed and notarized form must be attached to the record copy of any contract filed with the department. The form provides space for multiple authorized signatories and clearly specifies that signatures must be executed in ink on paper in the presence of a notary public.
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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)
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number)
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.
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
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
AFFIX NOTARY SEAL/STAMP
A copy of this document must be attached to the “record copy” of a contract filed with the department.
| Notarized Signature for Individual, Sole-Proprietor or Single Member LLC |
| (must match Form W-9 tax classification) |
| Contractor Legal Name: |
| Print Signatorys full legal name: |
| Title: |
| Print Notary Name: |
| Date: |
| My commission expires on: |
| Contractor Vendor/Customer Code: |
File details come from the government source that posted it. Updated .