Professional legal forms

Authorization to defer compens... RSA-1 DEFERRED COMPENSATION PLAN. Remit to Payroll Officer. Please Type or Print Using Black Ink. This form is to be used to begin, cease or change ...

Authorization to take courses... Print Form AUTHORIZATION TO TAKE COURSES ELSEWHERE Approval required before taking courses elsewhere, including Virginia Community Colleges Pamplin College of Business This form serves only as authorization

Treasury authorization form Treasury Collateral Management and Monitoring TCMM Agency Authorization Form Section 1 General Information Create Security Account Delete Security Account Add New User s Delete User Section 2 Agency Information Security Account Name of Agency Name of Bureau Address City Circle One State Zip code Dual Verification will be verified by another agency authorized individual Single Verification Section 3 User Profile s The individuals listed below are collateral contacts under the terms of Title 31 of the Code of Federal Regulations Part 202 or Part 225 and are authorized agency users of TCMM. Each user must have a unique and valid e-mail address. Name Title E-mail Address not shared Area Code Phone By signing below the Agency Official certifies that he/she is duly authorized by the Agency to designate individuals who can manage collateral accounts and serve as user s of TCMM. Name print Signature Title required Phone Fax Date / Please mail or fax the completed form to the TCMM Treasury Support Center Mailing Address TCMM Treasury Support Center Federal Reserve Bank of St* Louis P. O. Box 442 St* Louis MO 63166 866-707-6574 Overnight Address 1421 Dr. Martin Luther King Drive Internal Use Only Date/Time Confirmed with Authorizer Initials Date/Time Verified Authority and Title Date Entered Date Entry Verified Last Updated 09/11 General Notices To access TCMM Users may be issued authentication credentials such as a username and password. We the United States Department of the Treasury and its designated agents may rely upon the authentication credentials alone to provide access to TCMM. We may act upon on any electronic message that we establish to be associated with a known set of authentication credentials as if the message consisted of a written instruction bearing the ink signature of one of the Agency s duly authorized officials. An Agency accepts sole responsibility for and the entire risk arising from the use of authentication credentials by its Users. All Users must agree to terms and conditions governing access to TCMM. These terms and conditions can be found on the Web site s of the application s providing TCMM. These terms and conditions include provisions requiring Users to maintain the confidentiality of their authentication credentials to report the possible theft or compromise of their authentication credentials and to take action whenever they no longer require access or require access to a lesser extent than is currently the case. These terms and conditions are subject to change from time to time. We may have Users click-thru these terms and conditions before first use on a periodic basis or whenever they change to reflect their continued agreement to these terms and conditions. We will not be liable for any loss or damage resulting from a problem beyond our reasonable control* This includes but is not limited to loss or damage resulting from any delay error or omission in the transmission of any electronic information alteration of any electronic information any third party s interception or use of any electronic information a failure of services provided by an Internet service provider and malicious activity received from or introduced by a third party.

F8821 tax authorization form The IRS has created a page on IRS.gov for information about Form 8821 and its instructions at www.irs.gov/ form8821. If you wish to name more than one appointee attach a list to this form. CAF No. Name and address PTIN Fax No. Check if new Address 3 Tax matters. The appointee is authorized to inspect and/or receive confidential tax information in any office of the IRS for the tax matters listed on this line. Do not use Form 8821 to request copies...

2011 form 8879sp irs e file si... Formulario 8879(SP) Autorizaci n de Firma para Presentar la Declaraci n por medio del IRS e-file OMB No. 1545-0074 Department of the Treasury Internal Revenue Service No env e esta autorizaci n al

Kaiser disclosure form The written revocation will be effective upon receipt except to the extent that the disclosing party or others have acted in reliance upon this authorization. REDISCLOSURE I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Dispensing summary e.g. tax records. SPECIFY to RECORDS Request for the period from MNVDDW MMODW Records up to the past 36 months are available as a courtesy. Records beyond 37 months are assessed a service fee of 15. 00 per request / per member / patient. Enclose check or money order made to the order of Kaiser Foundation Hospitals KFH. Kaiser Foundation Health Plan Inc. KAISER PERIMIANENTE Southern California Permanente Medical Group Inc AUTHORIZATION FOR USE AND DISCLOSURE OF PHARMACY INFORMATION SOUTHERN CALIFORNIA I understand that Kaiser Permanente will not condition treatment payment enrollment or eligibility for benefits on my providing or refusing to provide this authorization. Disclose to I hereby authodze Kaiser Permanente Pharmacy Print Name of Recipient and / or Kaiser Foundation Hospital Pharmacy Address City State Zip Records and information pertaining to Medical Record Number Date of Birth Telephone Number DURATION This authorization shall become effective immediately and shall remain in effect for this single request for records after which the authorization shall expire. A new authorization form will be required for each future request. REVOCATION This authorization is also subject to written revocation by the member / patient at any time. The written revocation will be effective upon receipt except to the extent that the disclosing party or others have acted in reliance upon this authorization* REDISCLOSURE I understand that the recipient may not lawfully further use or disclose the health information unless another authorization is obtained from me or unless such use or disclosure is specifically required or permitted by law. Dispensing summary e*g* tax records. SPECIFY to RECORDS Request for the period from MNVDDW MMODW Records up to the past 36 months are available as a courtesy. Records beyond 37 months are assessed a service fee of 15. 00 per request / per member / patient. Enclose check or money order made to the order of Kaiser Foundation Hospitals KFH. DO NOT SEND CASH. The recipient may use the pharmacy health information authorized on this form for the following purposes A copy of this authorization is as valid as the original* Member / patient has a right to a copy of this authorization* Please send a copy of Power of Attorney Death Certificate or other legal document as it applies to request of records for another member / patient. Date. Make a copy for your records and Mail completed form to Version 6 REV 6-08 HIPAA COMPL ANT Signature If Signed by Other than Member/Patient Indicate Relationship Pharmacy Informatics PO Box 5075 Livermore CA 94551-5075 Faxed copies will not be accepted* FORM NOT TO BE USED FOR RESEARCH NDIVIDUAL ENROLLMENT OR ELIGIBILITY.

Genesis donor program anatomic... Medical Education & Research Institute Genesis Donor Program Anatomical Gift Authorization Form I, being of sound mind and body, do hereby freely (Type or print full name of Donor First, Middle,

Bluebiz benefit administrator... BlueBiz Benefit Administrator Authorization Form BlueBiz provides a single, secure way to access Blue Cross and Blue Shield of Florida (BCBSF) web-based capabilities. Complete and sign the appropriate

Authorization to release recor... Office of the General Counsel. FERPA Authorization Form. OGC-SF-2006-02 Revised 03.10.08. Page 1 of 1. Note: Modification of this Form requires approval of ...

New york city department of ed... NEW YORK CITY DEPARTMENT OF EDUCATION AUTHORIZATION FOR SIPP EXPENDITURE NON-EMPLOYEE PAYMENT REQUEST FORM For use in conjunction with the on-line SIPP Program Type or use black ballpoint pen. PRINT legibly to insure prompt payment. INSTRUCTIONS FOR COMPLETING FORM This form is to be used by non-Department of Education employees to record their attendance at Department of Education planning meetings or program activities that provide for payments to such individuals. Fixed rates for reimbursement have been established as a guide only and may be found in appropriate SOPM and/or memoranda on this topic* Actual invoices or individual receipts may be submitted in lieu of fixed rate reimbursement if actual expenses are higher than those suggested provided prior written approval is obtained from the Executive Director of the Division of Financial Operations. Regions may establish rates less than those suggested if no documentation is provided* The non-employee is responsible for completing information in Sections 1 through 3. In the box for Name of Program enter the specific name of the program such as School Based Management Parent Involvement Program School Wide Projects etc* The principal or other approving officer completes Section 4. The District/Central Business Office completes Section chairperson or to the Department of Education official responsible for the activity principal teacher-in-charge program coordinator etc* at each meeting to verify attendance. The completed form is to be sent to the Central or Region Office for review and payment processing through the On-Line SIPP System* In general allow five 5 to ten 10 days for the check to be issued and received through the mail* NOTE Consult program guidelines to determine if documentation supporting expenses is required* SECTION 1 REGION SCHOOL NAME OF PROGRAM SOCIAL SECURITY NUMBER NAME OF NON-EMPLOYEE Type or print legibly Apartment Number MAILING ADDRESS Number and Street CITY STATE ZIP CODE DATE OF MEETING MM DD YY MEETING PERIOD Hours Example 8 00 pm to 9 00 pm FROM TO TOTAL HOURS PAYMENT RATE OR ACTUAL EXPENSE OFFICIAL S SIGNATURE I certify that I have met the obligations as a member of the Enter name of program committee or activity and request the appropriate reimbursement of which will cover my actual expenses. SIGNATURE OF NON-EMPLOYEE DATE I approve this expenditure certifying that it is necessary for the conduct of the educational or administrative program and is in accordance with the rules and regulations of the Department of Education and applicable funding source guidelines. SIGNATURE OF PRINCIPAL OR APPROVING OFFICER FOR REGION/CENTRAL OFFICE USE ONLY FUNDS ARE AVAILABLE CHARGE TO ACTIVITY CODE LOCATION CODE QUICK CODE DATE Revised October 2004 OBJECT CODE AMOUNT Entered On-Line ENTERED BY AUTHORIZED BY COPY 1 FMC/Region Office COPY 2 School/Program Coordinator COPY 3 Non-Employee. INSTRUCTIONS FOR COMPLETING FORM This form is to be used by non-Department of Education employees to record their attendance at Department of Education planning meetings or program activities that provide for payments to such individuals. Fixed rates for reimbursement have been established as a guide only and may be found in appropriate SOPM and/or memoranda on this topic* Actual invoices or individual receipts may be submitted in lieu of fixed rate reimbursement if actual expenses are higher than those suggested provided prior written approval is obtained from the Executive Director of the Division of Financial Operations.

Authorization to release infor... Authorization To Release Information This release will be used for the purpose of facilitating and expediting the transaction contemplated by the listing agreement between the undersigned and . It

Dog name change authorization... Dog Name Change Authorization Note: items may be mailed separately $ $ $ 2 5 BV1AC Submit this form to request a change to the name of an AKC-registered dog that was whelped in the USA. Please read

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