DWI EBS Authorized Representative Delegation Form

DWI EBS Authorized Representative Delegation Form

The DWI EBS Delegation of the Claim Creator Role may be submitted by the authorized representative to delegate the responsibility of creating a claim in EBS.This form must be completed by the Authorized Representative named in the funding resolution (resolution used when accepting the funds). If an individual is identified in EBS as a Claim Creator, EBS will allow the user to create, view and edit claims for ALL active DWI projects for organizations (LGUs) that they have been authorized to access. Any questions regarding this DWI EBS Claim Creator Role Access Form can be submitted to DWIEBSSupport@deq.nc.gov.

Authorized Representative Information

Last Name*

First Name*

Job Title*

Organization Name (Legal Name of Entity - Registered with the NC Secretary of State)*

Email (as found on NCID)*

Federal Tax ID (Grant Receipient Tax ID)*

Request access for all of the organization's Federal Tax-ID #s in which you intend to delegate the creator claim role.

Delegated Claim Creator Role

Not authorized to submit but can create claims in EBS.

Last Name*

First Name*

Job Title*

Organization (Legal Name of Entity - Registered with the Secretary of State)*

Claim Creator Role NCID Username*

Email Address (as found on NCID)*

*Attestation: By submitting this request for a Claim Creator role, the Authorized Representative attests and agrees to the following:

1. I am authorizing the Claim Creator role as identified in this form to create claims on my behalf in EBS.

2. All information input by the Claim Creator role remains the responsibility Authorized Representative.

3. The accuracy of information, and all approval and submittals, will remain the sole responsibility of the Authorized Representative on record, and as identified above.

Please check to acknowledge Attestation.*

Signature*

Please submit your full name, which we will use as a form of signature.

Send me a copy of my responses

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