Form Da-04-121-Cardinal - Authorized Signatories (Commonwealth Of Virginia)
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1
2
3Form DA-04-121-Cardinal
(Rev. 12/15)
Authorized Signatories
Department of Accounts
Commonwealth of Virginia
Fiscal Year:
Agency Name:
Agency No.:
Agency Address:
Control Agency No.:
Fiscal Officer:
Phone No:
Fax No.:
Fiscal Officer E-Mail Address:
Fiscal Officer must sign below.
To the Comptroller: The employees whose signatures appear below or on the continuation sheets are authorized to perform one or more of the following: 1) approve
and release expenditure documents and transactions in CARS; 2) certify payroll for this agency, department or institution; 3) act as Payroll Security Officer; 4) act as the
CARS Security Officer; 5) act as the Cardinal Security Officer.
DOA Payroll Service Bureau (Participating Agency)
Yes
No
As a participating agency, the employees whose signatures appear on Form PSB-01-001, Authorized Parties for CIPPS Payroll Certification Entry, are authorized to enter
the CIPPS Payroll Certification details on behalf of the parties authorized to certify payroll for this agency, department or institution.
Cardinal Acknowledgement: The Cardinal Security Officers (CSOs) listed herein have been granted authority to add and delete users in Cardinal that are both preparers
and approvers of transactions in Cardinal. Persons granted select approver roles in Cardinal have the authority to approve and release revenue, and expenditure
documents and transactions for this agency, department or institution. The Head of agency, department, or institution, Fiscal Officer and the Cardinal Security Officers
understand that by approving a transaction in Cardinal (via online or via interface transmission), the agency, department or institution and its employees and agents agree
to the certifications contained in the Commonwealth Policy and Procedure (CAPP) Manual for the applicable transaction. Additionally, the CSOs, by signing below, agree
to adhere to CAPP Topic No. 70220, Cardinal Security, and the Cardinal Security Handbook.
Head of Agency, Department or Institution
Print Name:
Signature:
Title:
Date:
Agency Head Phone No.:
(This form remains effective through the end of the designated fiscal year).
C
Check
Signature:
S
Authorization:
O
Print Name:
Title:
C
P
CARS
S
S
Expend.
Payroll
O
O
Cardinal Security Officers Designations:
Primary Cardinal Security Officer
X
Phone:
E-mail:
Secondary Cardinal Security Officer
X
Phone:
E-mail:
(Two CARS Security Officers (CSO), Two Cardinal Security Officers (CSO) and a Payroll Security Officer (PSO) must be designated)
Return Completed Signature Card with Original Signatures to DOA, Compliance Assurance Unit. No. of continuation sheets ____
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Parent category: Business