ACH Liaison Designation {FM-139} | Pdf Fpdf Doc Docx | New York

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ACH Liaison Designation {FM-139} | Pdf Fpdf Doc Docx | New York

ACH Liaison Designation {FM-139}

This is a New York form that can be used for Department Of Motor Vehicles within Statewide.

Alternate TextLast updated: 8/3/2015

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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: ç ________________________________________________________________________________ Print Name:________________________________________________________________________________ Title: ____________________________________________________________________________________ Date (mm/dd/yyyy):__________________________________________________________________________ FM-139 (7/15) American LegalNet, Inc. www.FormsWorkFlow.com

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