Direct Contract Forms and Instructions - New York State Office of ...

CORPORATION/MUNICIPAL CORPORATION
IN WITNESS THEREOF, the parties hereto have executed or approved this AGREEMENT on the
dates below their signatures.
CONTRACTOR
Contract No.: C-00
STATE AGENCY
Office of Mental Health
By:
By:
Printed Name:
Title:
Date:
STATE OF NEW YORK)
) SS.:
County of:
Printed Name: Nancy P. Splonskowski
Title: Director, Contract & Claims Unit
Community Budget & Financial Mgmt
Date:
State Agency Certification
"In addition to the acceptance of this contract, I
also certify that original copies of this signature
page will be attached to all other exact copies of
this contract."
On this day of , 20 , before me personally came , to me
known, who being by me duly sworn, did depose and say that he/she resides at , and
that he/she is
of the corporation or municipality described in and which executed
the above instrument, and that he/she executed the above instrument by order of the board of
directors of the corporation and that he/she signed his/her name thereto by like order, or that he/she
was duly authorized by the municipal corporation described in and which executed the above
instrument, and that he/she executed the above instrument pursuant to authority vested in him/her.
Notary:
ATTORNEY GENERAL‘S SIGNATURE
STATE COMPTROLLER‘S SIGNATURE
Title:
Thomas P. DiNapoli
Title: Comptroller_______
By:
Date:
Date:
2010-11 ATL Direct Contract Forms and Instructions 7