Form Fms 2958 - Delegation Of Authority - Kansas Department Of The Treasury
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1
2RESET FORM
Financial Management Service
Kansas City Financial Center
P.O. Box 12599-0599
Date:__________________________
Kansas City , MO 64116
DELEGATION OF AUTHORITY
Section I - DELEGATION AND RE-DELEGATION
In Accordance with the authority vested in me by the head of this agency or his/her designee, I hereby delegate to the
individual whose name, title and signature samples appear below the authority to:
˜
˜
˜
Designate Certifying Officers
Authority
MAY /
MAY NOT Be Redelegated
˜
˜
˜
Other
:___________________
Authority
MAY /
MAY NOT Be Redelegated
(Specify)
Comments:________________________________________________________________________________
TYPE OF DELEGATION OR REVOCATION ACTION:
[CHECK ONE]
˜
˜
˜
ORIGINAL DELEGATION
RE-DELEGATION
REVOCATION
Section II - DESIGNEE
Full Legal Name:____________________________________________________________________________
˜
˜
Title:______________________________________________________
Head of Agency:
Yes /
No
Agency:___________________________________________________
Effective Date:___________________
Bureau:___________________________________________________
Phone:_________________________
Division:__________________________________
Email:___________________________________________
Section III - SIGNATURE SAMPLES OF DESIGNEE
[Designee must sign within all 4 boxes in BLACK INK]
Section IV - DELEGATOR SIGNATURE
[Delegator must sign within the box in BLACK INK]
Full Legal Name:_______________________________
Title:_________________________________________
Agency:______________________________________
Bureau: ______________________________________
Division:______________________________________
Phone:_______________________________________
Email:_____________________________________
Section V - RETURN ADDRESS OF DELEGATOR
Section VI - To Be Completed by FMS
Address:__________________________________________
Transmittal No.:________________________
__________________________________________
Accomplished Date: ____________________
__________________________________________
By:__________________________________
__________________________________________
FORM
FMS
2958
DEPARTMENT OF THE TREASURY
FORMALLY FMS FORM 2958 (12-08)
11-12
FINANCIAL MANAGEMENT SERVICE
I TFM 4A-3000
WHICH IS OBSOLETE
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