Authorized Signatures Change Form - CT Child Nutrition

For state use only
                          Connecticut State Department of Education                                 Effective date:
                          School Health, Nutrition and Family Services                     Agreement numbers:
                                                                                            School programs
                          Child Nutrition Programs
                                                                                             Child care centers
                          450 Columbus Boulevard, Suite 504                                  Adult day care centers
                          Hartford, CT 06103-1841                                            Day care homes
                                                                                             Summer food service


                                      Authorized Signatures Change Form

Read the Instructions for Completing the Authorized Signatures Change Form before completing this form. Scan
and e-mail the completed form to CNPermanentAgreement@ct.gov. Include “Authorized Signatures
Change Form” in the subject line of the e-mail.

 This is to certify that on February 7, 2023                                        , as shown in the minutes of
Colchester Board of Education                                                       the following action was taken to
 revise the authorized signers of the ED-099 Agreement for Child Nutrition Programs.

    1. Signature 1: The person designated below is authorized to sign this agreement and to sign claims
       for reimbursement.
                                                                           Daniel P. Sullivan, III
     Signature                                                              Printed name
    Superintendent of Schools
     Title (superintendent of schools, mayor, selectman, president,         Date
     chairperson of the board, pastor, or commissioner)
    dsullivan@colchesterct.org                                             (860) 537-7208
     E-mail                                                                 Phone number


    2. Signature 2: In the absence or incapacity of the first designated individual, the second
       person designated below is authorized to sign claims for reimbursement.
                                                                           Rachel L. Linkkila
     Signature                                                              Printed name
    Business Director
     Title (assistant superintendent, business official, principal,         Date
     headmaster, city or town manager, executive director, or deputy
     commissioner)
    rlinkkila@colchesterct.org                                             (860) 537-7233
     E-mail                                                                 Phone number


    3. Signature 3: The signature below certifies the above action.

                                                                           Town Clerk
     Signature                                                              Title (secretary of corporation, town clerk, secretary of
                                                                            the board)

This form is available at https://portal.ct.gov/-/media/SDE/Nutrition/NSLP/Forms/
Authorized_Signatures_Change_Form.pdf. This institution is an equal opportunity provider.

                                     Connecticut State Department of Education • Revised June 2022