AUTHORIZED OSPA SIGNATURES
This form establishes permission for the individuals named to request off-cycle
manual checks and pay advances from OSPS.
Existing Signatures Verified
Hand-written Info? Yes No
If Yes, email verification rec’d on: ________
Retired and moved to Inactive tab on: (Retention: 6 years)
PAYROLL SERVICES /
PAYROLL SYSTEM SUPPORT
Fax: (503) 378-3518
1. COMPLETE ONLINE ONLY.
2. For each signer, select and
replace the “Not Used”
with a name.
3. Choose the authority
level(s) for each name.
4. Complete the agency
5. Print form and collect
6. Return ORIGINAL form to
If you need immediate
approval, you may fax the
form to OSPS; we will honor
the fax for three days while
the original is in transit.
OSPS Use Only
Received Date Stamp
Form No. 75.45.01.FO
Section A: Authorized Signers (use additional pages as needed; check box below list)
I certify: Payroll Advances will comply with OAM Policy 45.25.00.PO, applicable collective
bargaining agreement, and/or agency policy as appropriate.
CHECK ONE: This is the only page This is Page _____ of _____.
Hand-written information will be verified by OSPS through the person listed in Section B.
Section B: Administrator Authorization and Alternate Designee
NOTE: Nobody in this section can be listed in Section A as an authorized signer.
I authorize the individuals listed in Section A to submit check requests to OSPS on behalf of:
Administrator Printed Name
Future updates may be authorized by (optional alternate designee):
Alternate Designee Printed Name