Acknowledgments and Signatures Sample Clauses

Acknowledgments and Signatures. The Donor acknowledges that Xxxx Community Foundation independently administers the application and selection process for the Xxxx Community Impact Grant and that the Donor’s funding of a grant has no influence over the determination of grant recipients. DONOR 1 Signature Printed Name Date DONOR 2 Signature Printed Name Date FOR XXXX COMMUNITY FOUNDATION, INC. (Executive Director or Officer of the Board): Signature Printed Name Title
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Acknowledgments and Signatures. All dividends paid to your Xxxx XXX will be reinvested in addition- al shares of Wal-Mart stock. Please note the current Xxxx XXX fee schedule. Information concerning the ability to revoke this Xxxx XXX may be found in the Xxxx XXX Disclosure Statement. Please sign and date the Enrollment Form. Keep a copy of the Enrollment Form and these Instructions for your records. Staple the original Enrollment Form to your check(s) for the annual fee and any contribution(s), and the transfer form, if applicable. April Deadline Your signed Enrollment Form for the Xxxx XXX Program must be received at the address on this form on or before your tax-filing deadline (no extensions) to be eligible to receive contributions for that tax year. Your contribution check must be postmarked to us at the address on this form no later than your tax-filing deadline (no extensions).
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Acknowledgments and Signatures. I, the undersigned, designate Computershare Trust Company, N.A. as Trustee of my Xxxx XXX and certify that I have received, read and agree to abide by the terms and conditions set forth in the prospectus describing the Wal-Mart Stores, Inc. Shareholder Investment Program and the Xxxx XXX Individual Retirement Trust Agreement and Disclosure Statement and this Xxxx XXX Enrollment Form and Instructions. I direct Computershare Trust Company to apply dividends and any contributions made to this Xxxx XXX to the purchase of shares of Wal-Mart common stock under the Wal-Mart Stores, Inc. Shareholder Investment Program. I understand all dividends paid on Wal-Mart common stock held in my Xxxx XXX will be reinvest- ed in additional shares. I acknowledge and accept the Xxxx XXX Program fee schedule and authorize deduction of any such fees from my Xxxx XXX if I do not make direct payment. I understand I may revoke this authori- zation at any time by terminating my Xxxx XXX. In witness whereof, I evidence adoption of the Xxxx XXX Program by execution of this Enrollment Form on the date below. Account Owner's Signature X Social Security # I hereby warrant under penalty of perjury that the Social Security number provided above is correct. Date
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Acknowledgments and Signatures. Please note the disclosures (including the Xxxxxxxxx ESA fee schedule), and sign and date the Enrollment Form. Keep a copy of the form and these instructions for your records. Staple the original Enrollment Form to a check(s) for the annual fee and your contribution. Send the form and check(s) to the address on this form. Form 5305-E (rev. March 2002) Department of the Treasury Internal Revenue Service Xxxxxxxxx Education Savings Trust Account (Under Section 530 of the Internal Revenue Code) Do NOT file with the Internal Revenue Service This Xxxxxxxxx Education Savings Trust Account formerly was known as the Education Individual Retirement Trust Account. The Grantor whose name appears on the Xxxxxxxxx Education Savings Trust Account ("Xxxxxxxxx ESA") enrollment form ("Enrollment Form") is establishing a Xxxxxxxxx Education Savings Trust Account under section 530 for the benefit of the Designated Beneficiary whose name appears on the Enrollment Form exclusively to pay for the qualified elementary, secondary, and higher education expenses, within the meaning of section 530(b)(2), of such Designated Beneficiary. Computershare Trust Company, N.A., (the "Trustee") has given the Grantor the required disclosure statement, a copy of the Program Literature, and has agreed to serve as Trustee of this Xxxxxxxxx ESA. The Grantor has assigned the Trust the sum indicated on the Enrollment Form. Such amount and any additions thereon from time to time held by the Trustee pursuant to this agreement may be herein referred to as the "Trust Account," "Trust," or "Trust Funds." The Grantor and the Trustee make the following agreement:
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Related to Acknowledgments and Signatures

  • Counterparts and Signatures The Agreement may be executed in multiple counterparts, each of which shall be deemed an original, but all of which taken together shall constitute one and the same instrument. A Party may evidence its execution and delivery of the Agreement by transmission of a signed copy of the Agreement via facsimile or email. In such event, the Party shall promptly provide the original signature page(s) to the other Party.

  • Required Signatures a. Curriculum Academic Xxxx(s) b. Curriculum Chair(s)

  • Authorized Signatures (1) Each of the undersigned represents that he or she is fully authorized to enter into the terms and conditions of, and to execute, this Settlement Agreement on behalf of the Parties identified above their respective signatures and their law firms.

  • Authorized Signatories The parties each represent and warrant to the other that (1) the persons signing this lease are authorized signatories for the entities represented, and (2) no further approvals, actions or ratifications are needed for the full enforceability of this Lease against it; each party indemnifies and holds the other harmless against any breach of the foregoing representation and warranty.

  • Authorized Signature Your signature on the Account Card authorizes your account access. We will not be liable for refusing to honor any item or instruction if we believe the signature is not genuine. If you have authorized the use of a facsimile signature, we may honor any check or draft that appears to bear your facsimile signature even if it was made by an unauthorized person. You authorize us to honor transactions initiated by a third person to whom you have given your account number even if you do not authorize a particular transaction.

  • Counterpart Signatures For the purpose of facilitating the recordation of this Agreement as herein provided and for other purposes, this Agreement may be executed simultaneously in any number of counterparts, each of which counterparts shall be deemed to be an original, and such counterparts shall constitute but one and the same instrument.

  • No Signature Required When any payment or other online Service generates items to be charged to your account, you agree that we may debit your Bill Payment account without requiring your signature on the item, and without prior notice to you.

  • Counterpart Signature This Agreement may be signed in counterpart, and the signed copies will, when attached, constitute an original Agreement.

  • Student Signature By signing this contract, Resident agrees to pay the contract amount (room, board and association fees) in accordance with Addendum B: Rate and Payment Schedule. Resident may pay the full amount due prior to the due date, at the Resident’s election.

  • AGREEMENT SIGNATURES By signing below, both parties agree to the terms and conditions of this Agreement. Please acknowledge acceptance of this document and terms by returning a signed copy within seven (7) days of issuing. If a signed copy is not returned within seven (7) days and you are attending service, Fighting Chance will deem this to be acceptance of the document. If signed by Xxx XxxXxxxxxxX: Signature of Participant: Date: If signed by Person Responsible: I confirm that this Agreement has been explained to the individual receiving the services and that they agree to the terms. I further confirm that I have authority to sign on their behalf. Signature of Person Responsible: Date: SignaĒure on behalf of FighĒing Chance: Signature of Person(s) responsible: Date: Name: Appendix 1 Key Contact Details Participant’s Name Participant’s Email Participant’s Phone Participant’s Address Person(s) responsible’s Name Person(s) responsible Relationship to Participant Person(s) responsible’s Email Person(s) responsible’s Phone Support Coordinator (where applicable) Support Coordinator’s Name Support Coordinator’s Email Support Coordinator’s Phone Shared Living/Supported Accommodation/Group Home (if applicable) House Manager’s Name House Manager’s Email House Manager’s Phone Additional Contacts (if applicable) Role Contact’s Name Contact’s Email Contact’s Phone Appendix 2 NDIS Claiming Preferences Fighting Chance supports NDIS participants who are NDIA-Managed, Self-Managed or Plan Managed. To invoice and bill you correctly, it is important you keep us updated with your plan management preferences, and let us know ongoing if your status changes. For the purposes of services delivered by Fighting Chance, your NDIS plan is: (please tick) ☐ NDIA-MANAGED You understand that Fighting Chance will claim directly through the NDIA portal if your funding for Fighting Chance is NDIA-managed, so you will not receive any direct request for payment from us. To ensure that you do not get a text from the NDIA to approve each claim weekly, endorse Fighting Chance as a ‘My Provider’ for automatic payment processing. Instructions can be found at xxxxxxxxxxxxx.xxx.xx/xxxx/ or you can contact the Fighting Chance My Provider Endorsement Helpdesk on (00) 0000 0000 or xxxxxxxxxxxxxxx@xxxxxxxxxxxxx.xxx.xx ☐ (Optional) Please supply me, by email, with monthly Statements of Account to: ☐ SELF-MANAGED ☐ I am self-managed and would like to be invoiced for services once a week. Please email invoices to: Please see Appendix 3 for Self-Management Payment Options. ☐ PLAN-MANAGED Please send invoices to my plan manager: Plan management organisatio Contact Name Email Address Phone number ☐ OTHER FUNDING (eg. self-funded, iCare or other insurance funding) Please email invoices to: Appendix 3 Self-Managed Payment Options Participants who are self-managed have a number of payment options with Fighting Chance: ☐ DIRECT DEPOSIT (preferred option) Payment of Fighting Chance invoices can be made by Electronic Funds Transfer (EFT) through your bank. Fighting Chance’s bank account details are as follows: Bank: Commonwealth Bank of Australia Account Name: Fighting Chance Australia Ltd BSB: 062-438 Account Number: 00000000 To ensure all payments are correctly allocated to your account, please include the full invoice number in the reference field. ☐ CREDIT CARD Payments can be made by credit card by clicking the ‘pay by credit card’ link included on the invoice. Please note that a service fee for this option will be imposed. ☐ PAYPAL Payment of your invoices can also be made via our PayPal account. To make payment via PayPal, please access the following link: xxxxx://xxxxxx.xx/FightingChanceAus?locale.x=en_AU To ensure your payment is correctly allocated, please enter the full invoice number in the reference field. Appendix 4 Non Face to Face Time Breakdown - Jigsaw Standard Non Face-to-Face Supports Delivered to every Jigsaw Participant daily, weekly, annually Writing the Board (i.e. preparing and writing up each person’s individualised program for the following day). Reviewing Trainee records/journal notes/medical or other key information to be able to best support the person during their day. Parent/Guardian/Carer Updates, i.e. emails, phone calls. Pre- and post-shift sta briefings. Zone setup (setting up workstations, boxes, visuals and group training areas) Resource development to support each Trainee to progress towards their employment goals (adapting training resources, creating visual aids and cheat sheets, etc). Research/Coordination to implement support strategies (disability, behavioural and learning strategies). Family reviews and the development of training plans (planning, delivery and follow up). Planning social events and extra curricular training (e.g. TAFE). Standard NDIS Annual Support Review Letter. Standard Ǫuarterly Reports - Upon Request. Complex Non Face-to-Face Supports - Delivered to Jigsaw Participants with High Intensity Support Needs (in addition to supports outlined in Standard) Allied health meetings, phone calls, correspondence. Specialist/additional sta training (internal or external), i.e. BSP implementation training. Creation of additional/detailed social stories/visuals. Data collection requested by behaviour therapists. Incident follow up or crisis meetings (seperate to regular family updates or regular allied health meetings). Development/review/discussion of medication forms/transfer plans/mealtime assistance plans etc. Detailed and regular sta training on individual complex behaviour/medical/transfer/mealtime support plans. Extended daily pre-brief and debrief. Additional Non Face-to-Face Supports - billed separately upon request Detailed NDIS Review Letters One-o engagement or training with Allied Health. Detailed Ǫuarterly Reports.

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