Form Fms 210co - Designation For Certifying Officer - Kansas City Financial Center
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1
2RESET FORM
Financial Management Service
Kansas City Financial Center
P.O. Box 12599-0599
Date:__________________________
Kansas City , MO 64116
DESIGNATION FOR CERTIFYING OFFICER
Section I - DESIGNATION AND RE-DESIGNATION
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 act as a Certifying Officer (CO) for the following Agency Location Codes (ALCs):
________________
________________
________________
[LIST EACH ALC THE CO IS AUTHORIZED FOR:]
________________
________________
________________
________________
________________
________________ ________________
________________
________________
________________
Comments:________________________________________________________________________________
TYPE OF DESIGNATION OR REVOCATION ACTION:
[CHECK ONE]
˜
˜
˜
ORIGINAL DESIGNATION
RE-DESIGNATION
REVOCATION
Section II - DESIGNEE
Full Legal Name:____________________________________________________________________________
Title:______________________________________________________
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 - DESIGNATOR SIGNATURE
[Designator must sign within the box in BLACK INK]
Full Legal Name:_______________________________
Title:_________________________________________
Agency:______________________________________
Bureau: ______________________________________
Division:______________________________________
Phone:_______________________________________
Email:_____________________________________
Section V - RETURN ADDRESS OF DESIGNATOR
Section VI - To Be Completed by FMS
Address:__________________________________________
Transmittal No.:________________________
__________________________________________
Accomplished Date: ____________________
__________________________________________
By:__________________________________
__________________________________________
FORM
FMS
210CO
DEPARTMENT OF THE TREASURY
FORMERLY FMS FORM 210CO (12-08)
11-12
I TFM 4A-3000
WHICH IS OBSOLETE
FINANCIAL MANAGEMENT SERVICE
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