TO BE PLACED ON
SCHOOL DISTRICT LETTERHEAD

SAMPLE AUTHORIZATION LETTER

(Date)
(County name)
(County address)

SUBJECT: SIGNATURE AUTHORIZATION PRESCHOOL

Dear (Name of §4410 Municipality Representative):

Please accept this letter as the extension of my authorization to cover electronic STAC data transmissions by (name of county) to the STAC and Medicaid Unit.

This authority has been extended to cover the electronic data transmissions with the condition that (name of county) maintains documentation necessary to support an audit.  Upon receipt and approval of the electronic information by SED, approval information will be available online on the STAC database. The District will be responsible for reviewing the approval information for accuracy and initiating corrections if necessary.

This authorization is intended to be operative for the school year 20__ - __ and must be renewed annually.

Name of Superintendent: ________________________________________________________
Signature of Superintendent: _____________________________________________________
School District Name: __________________________________________________________
Date: ___________________ Telephone: ___________________ Fax: ___________________