contractor-authorized-signatory-listing-sole-proprietors~46.pdf
PDF 195 KB Posted
- Solicitation number
- BD-27-1084-POLGH-GHQ-131375
- Issued by
- Massachusetts
About this file
This is a Contractor Authorized Signatory Form jointly issued by the Commonwealth of Massachusetts Office of the Comptroller (CTR) and the Operational Services Division (OSD) for use by all state departments when no other form is prescribed by regulation or policy. The form is designed to establish authorized signatories for contractors, sole proprietors, and individuals who will execute contracts and other legally binding documents on behalf of the contracting entity. The form requires a notarized signature from the authorized representative, with the signatory's printed name, title, and the notary public's certification including commission expiration date. A copy of the completed form must be attached to the record copy of any contract filed with the respective department.
The form emphasizes data protection protocols by explicitly prohibiting the attachment of personally identifiable information such as bank account numbers, social security numbers, driver's licenses, home addresses, or social security cards to the submission. The Commonwealth reserves the right to publish the names and titles of authorized signatories as part of public records. The notarized signature must match the contractor's Form W-9 tax classification and be executed in the presence of a notary public who must verify the signatory's identity through satisfactory evidence and obtain the notary's official seal or stamp on the document.
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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 .