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ACH Liaison Designation FM-139 - New York

ACH Liaison Designation Form. This is a New York form and can be used in Department Of Motor Vehicles Statewide .
 Fillable pdf Last Modified 7/16/2015
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ACH LIAISON DESIGNATION FINS Account Number: __________________________________ Account Name: ____________________________________________________________________________ Liaison Name: ____________________________________________________________________________ Liaison ID Number: ______________________________________ (From Driver's License or ID) Issuing State of Driver's License or ID Card: __________________ Liaison E-mail Address: ____________________________________________________________________ I authorize above-named person to be the ACH liaison for this account. Signature: รง ________________________________________________________________________________ Print Name:________________________________________________________________________________ Title: ____________________________________________________________________________________ Date (mm/dd/yyyy):__________________________________________________________________________ FM-139 (7/15) American LegalNet, Inc.
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