Form Fm-139 - Ach Liaison Designation

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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.
ç
Signature: ________________________________________________________________________________
Print Name:________________________________________________________________________________
Title: ____________________________________________________________________________________
Date (mm/dd/yyyy):__________________________________________________________________________
FM-139 (7/15)
reset/clear

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