Form 51a290 - Information Sharing And Assignment Agreement For Designated Refund Claims Page 3
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51A290 (10-07)
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.
____________________________________________________
By ________________________________________________
Approved Co./Agency
(Signature of authorized signatory for Approved Company/
Agency)
Date _______________________________________________
____________________________________________________
Subscribed and sworn before me this
(Print name of authorized signatory for Approved Company/
the _____ day of ________________, 20___.
Agency)
____________________________________________________
____________________________________________________
Title
Notary Public
State at Large
My Commission Expires: _____________.
____________________________________________________
By ________________________________________________
Vendor
(Signature of authorized signatory for Vendor)
Date _______________________________________________
____________________________________________________
Subscribed and sworn before me this
(Print name of authorized signatory for Vendor)
the _____ day of ________________, 20___.
____________________________________________________
____________________________________________________
Title
Notary Public
State at Large
My Commission Expires: _____________.
____________________________________________________
By ________________________________________________
Contractor/Subcontractor (Purchaser)
(Signature of authorized signatory for Contractor/Subcontractor
(Purchaser))
Date _______________________________________________
____________________________________________________
Subscribed and sworn before me this
(Print name of authorized signatory for Contractor/Subcontractor
the _____ day of ________________, 20___.
(Purchaser))
____________________________________________________
____________________________________________________
Title
Notary Public
State at Large
My Commission Expires: _____________.
By ________________________________________________
Department of Revenue
(Signature of authorized signatory for Department of Revenue)
Date _______________________________________________
____________________________________________________
Subscribed and sworn before me this
(Print name of authorized signatory for Department of Revenue)
the _____ day of ________________, 20___.
____________________________________________________
____________________________________________________
Title
Notary Public
State at Large
My Commission Expires: _____________.
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