MRS_Contractor_Authorized_Signatory_Form.pdf
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- Attached to
- HLC0000123 Winter Bed NOFA
- Solicitation number
- BD-27-1076-OCDDE-HS003-133443
- Issued by
- Massachusetts
About this file
This is a Contractor Authorized Signatory Listing form jointly issued by the Commonwealth of Massachusetts Office of the Comptroller and Operational Services Division for use by state departments when executing contracts and legally binding documents with external contractors. The form requires all contractors, except sole proprietors and individual contractors, to designate authorized representatives who are empowered to sign contracts and related documents on behalf of the contractor. The document establishes procedures for listing authorized signatories and their relevant contact information, including name, signature, title, phone number, and email address. A responsible authorized officer of the contractor must certify the listed signatories and maintain the form as a current record of those authorized to execute Commonwealth agreements. The form includes an example showing the City of XYZ with two authorized signatories: Jane Doe (Program Manager) and Mary Smith (Director), with Mary Smith serving as the certifying officer.
The form specifies critical requirements and restrictions governing authorized signatory designations. At minimum, a contractor must designate at least two different authorized signatories, and no individual may serve as the sole signer or self-certify their own signature. The signatory certifying the form must have delegatory authority and, if planning to sign contracts, must also be listed among the authorized signatories. Signatures may be executed in three acceptable formats: traditional wet signatures, hand-drawn electronic signatures, or digitally affixed signatures through tools such as Adobe Sign or DocuSign, but typed text and computer-generated cursive are not acceptable. The contractor bears responsibility for immediately updating the Commonwealth departments with which it conducts business whenever authorized signatories retire, are terminated, or have their responsibilities changed, and acceptance of payment under any contract constitutes a waiver of any defense challenging the contract's validity based on lack of signatory authority.
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Commonwealth of Massachusetts
CONTRACTOR AUTHORIZED SIGNATORY LISTING
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.
Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company (must match Form W-9 tax classification)
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number or Social Security Number)
INSTRUCTIONS: Any Contractor (other than a sole-proprietor or an individual contractor) must provide a listing of individuals who are authorized as legal representatives of the Contractor who can sign contracts and other legally binding documents related to the contract on the Contractor’s behalf. In addition to this listing, any state department may require additional proof of authority to sign contracts on behalf of the Contractor, or proof of authenticity of signature (a notarized signature that the Department can use to verify that the signature and date that appear on the Contract or other legal document was actually made by the Contractor’s authorized signatory, and not by a representative, designee or other individual.)
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.
There are three types of electronic signatures that will be accepted on this form: 1) Traditional “wet signature” (ink on paper); 2) Electronic signature that is either: a. hand drawn using a mouse or finger if working from a touch screen device; or b. An upload picture of the signatory’s hand drawn signature; 3) Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign. Typed text of a name not generated by a digital tool, computer generated cursive, or an electronic symbol are not acceptable forms of electronic signature.
Authorized Signatory Name
Signature (Signature as it will appear on contract or other documents)
Title Phone Number
Email Address
Acceptance of any payment under a Contract or Grant shall operate as a waiver of any defense by the Contractor challenging the existence of a valid Contract due to an alleged lack of actual authority to execute the document by the signatory.
I certify that I am a responsible authorized officer of the Contractor and as an authorized officer of the Contractor I certify that the names of the individuals identified on this listing are current as of the date of execution and that these individuals are authorized to sign contracts and other legally binding documents related to contracts with the Commonwealth of Massachusetts on behalf of the Contractor. I understand and agree that the Contractor has a duty to ensure that this listing is immediately updated and communicated to any state department with which the Contractor does business whenever the authorized signatories above retire, are otherwise terminated from the Contractor’s employ, have their responsibilities changed resulting in their no longer being authorized to sign contracts with the Commonwealth or whenever new signatories are designated.
Please note you cannot self-certify your own signature as a single signer listed above.
Signature Date
Print Name Phone Number
Title Email Address
A copy of this listing must be attached to the “record copy” of a contract filed with the department.
Updated 8.22.24
Commonwealth of Massachusetts Executive Office of Public Safety and Security
Office of Grants and Reasearch
Helpful Hints for Completing the Contractor Authorized Signatory Form
• The individual signing on the bottom portion must have the authority to delegate the authorized signatories on the top of the form.
• There must be at least two (2) different signatures within the “Authorized Signatory Name” section that are authorized to sign contracts and subgrant conditions.
• If the signatory on the bottom of the form plans to sign contracts/subgrant conditions, they must also be listed in the “Authorized Signatory Name” section. Please Note: An individual cannot self-certify their own signature. (i.e., Mary Smith cannot be the sole signatory listed in the “Authorized Signatory Name” section and must designate at least one other signatory)
• Each person listed in the “Authorized Signatory Name” section of the form must include an accompanying signature.
• IMPORTANT: The signature shown in the chart should reflect how it will appear on the Standard Contract Form and OGR Grant Conditions. If the signature is handwritten on the CASL chart, then it should be handwritten on the Standard Contract and OGR Grant Conditions. If the signature is electronically affixed using a digital tool on the CASL chart, then it should be electronically affixed using the same digital tool as the contract documents.
Contractor Legal Name Contractor Vendor/Customer Code (if available, not the Taxpayer Identification Number or Social Security Number)
City of XYZ VC11111111111111
Authorized Signatory Name
Signature (as it will appear on contract or other documents) Title Phone Number Email Address
Jane Doe Program Manager 555-555-5555 Jane.Doe@XYZ.gov
Mary Smith Director 222-222-2222 Mary.Smith@XYZ.gov
Please note you cannot self-certify your own signature as a single signer listed above
Signature Date
Print Name
Mary Smith
Phone Number
222-222-2222 Title
Director Email Address
Mary.Smith@XYZ.gov
A copy of this listing must be attached to the “record copy” of a contract filed with the department
| 087 - MRS_Contractor_Authorized_Signatory_Form.pdf |
| CONTRACTOR AUTHORIZED SIGNATORY LISTING |
| Signature for Corporation (C or S), Partnership, Trust/Estate, Limited Liability Company (must match Form W-9 tax classification) |
| Helpful Hints for Completing the Contractor Authorized Signatory Form |
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| Contractor Legal Name: |
| Signature: |
| Date: |
| Print Name: |
| Phone Number: |
| Title: |
| Email Address: |
| Contractor Vendor/Customer Code: |
| Signature 1: |
| Title 1: |
| Phone Number 1: |
| Email Address 1: |
| Authorized Signatory Name 1: |
| Authorized Signatory Name 2: |
| Authorized Signatory Name 3: |
| Authorized Signatory Name 4: |
| Signature 2: |
| Signature 3: |
| Signature 4: |
| Title 2: |
| Title 3: |
| Title 4: |
| Phone Number 2: |
| Phone Number 3: |
| Phone Number 4: |
| Email Address 2: |
| Email Address 3: |
| Email Address 4: |
File details come from the government source that posted it. Updated .