Colchester, Connecticut

ED099 Child Nutrition Program signature form

Board of Education Meeting

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contract / agreement FY 2019-20 BoardDocs (BOE meetings) 2020-02-11

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Connecticut State Department of Education FOR STATE USE ONLY

Bureau of Health/Nutrition, Family

Services and Adult Education Eifetive Date:

Child Nutrition Programs AGREEMENT NUMBERS:

450 Columbus Boulevard, Suite 504 School Programs

Hartford, CT 061 03-1841 Child Day Care Centers
Authorized Signatures Change Form Adult Day Care Centers

Day Care Homes

Read the /nstructions to Complete the Authorized Signatures Summer Food Service
Change Form before completing the form. Return this form to

 

 

the CSDE Child Nutrition Programs at the address above.

c
This is to certify that on T2 | WUG 4 LL,.2020 _ , as shown in the minutes of
ate

Colchester beard of Educahon

Name of Corporation, Board of Education or Governing Body

the following action was taken to revise the Authorized Signers of the ED-099 Agreement for Child
Nutrition Programs.

1. The person designated below is authorized to sign this agreement and to sign claims for

 

 

reimbursement. LP-—
Telhrey burt
Signature Printed Name
Stporivtenlon 2)5)2020
Title (superintendent of schools, mayor, selectman, president ' Date

or chairperson of the board, pastor, or commissioner)

2. In the absence or incapacity of the first designated individual, the second person
designated below is authorized to sign claims for reimbursement.

Mh Wurst > N. Maggie (sg rove.
Sl Signature Prinied Nai
(niek “Hinanc ral wochice a rl Clooze

5 > v
Title (assistant superintendent, business official, principal, headmaster, city ot!
or town manager, executive director, or deputy commissioner)

 

3. The signature below certifies the above action.

Beard Clerk

Signature Title (Secretary of Corporation, Town
Clerk, Secretary of the Board)

 

 

This form is available at https: /fportal. ct:gov/-/media/SDE/Nuttition/NSLP/F orms/SignatureChange. pdf. The
instructions are available at https://portal.ct.gov/~ /media/SDE/Nutrition/NSLP/F. orms/SignatureChangeInstructions.pdf.

 

Connecticut State Department of Education e Revised August 2019