Form 51a601 - Information Sharing And Assignment Agreement For Disaster Relief Refund Claims - Commonwealth Of Kentucky Department Of Revenue Page 3
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51A601 (4-12)
This Agreement shall be effective upon its execution below by all applicable parties. The persons executing the agreement on behalf of
the parties warrant that they are duly authorized to execute this agreement on behalf of the parties.
_____________________________________________________
Legal Building Owner
_____________________________________________________
Date ________________________________________________
(Signature)
_____________________________________________________
Vendor
_____________________________________________________
By __________________________________________________
(Print name of authorized signatory for Vendor)
(Signature of authorized signatory for Vendor)
_____________________________________________________
Date ________________________________________________
Title
_____________________________________________________
Contractor/Subcontractor (Purchaser)
_____________________________________________________
By __________________________________________________
(Print name of authorized signatory for Contractor/Subcontractor
(Signature of authorized signatory for Contractor/Subcontractor
(Purchaser))
(Purchaser))
_____________________________________________________
Date ________________________________________________
Title
Department of Revenue
_____________________________________________________
By __________________________________________________
(Print name of authorized signatory for Department of Revenue)
(Signature of authorized signatory for Department of Revenue)
_____________________________________________________
Date ________________________________________________
Title
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