- Form MV-44DRF - Resident Disaster Victims Relief Supplemental Information and Attestation - New York
- Form FM-139 - ACH Liaison Designation - New York
- Form MV-15GC - General Consent for Release of Personal Information - New York
- Form MV-15C - Request for Driving Record Information - New York
- Form MV-15 - Request for DMV Records - New York
- Form FM-138 - Authorization Agreement for Direct Deposits - New York
Fillable Printable Form FM-139 - ACH Liaison Designation - New York
Fillable Printable Form FM-139 - ACH Liaison Designation - New York
Form FM-139 - ACH Liaison Designation - New York
Signature: ________________________________________________________________________________
Print Name:________________________________________________________________________________
Title: ____________________________________________________________________________________
Date (mm/dd/yyyy):__________________________________________________________________________
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.
FM-139 (7/15)
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