FS Form 2958DO Department of the Treasury | Bureau of the Fiscal Service Revised April 2021

DELEGATION OF AUTHORITY

DEPARTMENT OF THE TREASURY

BUREAU OF THE FISCAL SERVICE 

P.O. Box 12599-0599, Kansas City, MO 64116

Production.Support.Section@fiscal.treasury.gov

Date Completed:

SECTION I – DESIGNEE

a. Information

Full Legal Name - First:* Middle: Last:*

Agency:* Bureau:*

Phone Number:* E-mail:*

Title: HEAD OF AGENCY: YES NO

b. Request Type [Check One]

Original Delegation Update (Comments Required) Revocation

Comments:

c. Signature

Note one: To submit digitally, both the designee and delegator must digitally sign.

Note two: If digitally registered and INK memo authority is needed, please print your digital request, provide two signature samples, scan, and submit via the registered designee 

e-mail. A delegator ink signature is not required for a registered user to submit optional INK signature samples via their registered e-mail.

c.1. Digital Signature c.2. Ink Signature Samples

SECTION II – DELEGATOR

d. Delegation

In accordance with the authority vested in me, through a Fiscal Service approved 2958DO form, I hereby delegate to the individual whose name, title, 

and signature samples appear above, effective date , the authority to:.

 Delegate Authority to Designating Officials

 Designate Certifying Officers, Data Entry Operators, Designated Agents

e. Signature

Option one: To submit digitally, both designee and delegator MUST digitally sign and then e-mail the digitally signed document for processing.

Option two: To submit with ink signatures, both the designee and delegator must ink sign and then mail the original document for processing.

e.1. Digital Signature e.2. Ink Signature

Full Name:*

Agency:*

SECTION III – POINT OF CONTACT SECTION IV – FISCAL SERVICE VALIDATION

f. Information

Name:*

Address:

E-mail:* 

 Phone:

WHEN COMPLETED, THIS FORM BECOMES A “SENSITIVE BUT UNCLASSIFIED” (SBU) DOCUMENT

OR

Date

OR
FS Form 2958DO Department of the Treasury | Bureau of the Fiscal Service Revised April 2021

INSTRUCTIONS FOR FS FORM 2958DO

1. This form is for use by individuals authorized by the Head of Federal Entity (or his/her designee) to delegate authorities, such as designating 

Certifying Officers, to other individuals in the agency. The form must be submitted to the Bureau of the Fiscal Service. 

2. Delegations/Designations are valid for a period of two (2) years from the effective date. At the end of that period they will expire, unless a 

delegation renewal letter is submitted to the Bureau of the Fiscal Service. This form may be used for original delegations, updates, and revocations.

3. For “Effective Date,” enter the date that the delegation is to become effective. Delegations are valid for a period of two (2) years from either the effective 

date or Fiscal Service processing date, whichever one is later.

4. Authority for only one individual may be delegated or revoked per form.

5. All required fields are marked with (*) and must be completed, in order for Fiscal Service to process the form.

6. Email digitally completed and signed forms to: Production.Support.Section@fiscal.treasury.gov

7. Forms completed in ink should be mailed to: DEPARTMENT OF THE TREASURY

BUREAU OF THE FISCAL SERVICE

4241 NE 34th STREET 

KANSAS CITY, MO 64117

SECTION I - DESIGNEE

a. Information

• Enter the Full Legal Name of the Designee. Enter the other identifying information.

• Check Yes or No for the Head of Agency.

b. Request type

• Check the appropriate box for “Type of Delegation or Revocation Action.” Only one box may be checked.

- Check “Original Delegation” for new delegations.

- Check “Delegation Update” to update information for existing delegations.

- Check “Revocation” to revoke all authority that was originally delegated. If partial authority is to be retained from the original delegation,

a new FS Form 2958DO must be submitted re-delegating that authority.

c. Signature

• Digitally or manually sign in the appropriate signature box. Digitally signed forms must be emailed to Fiscal Service.

SECTION II - DELEGATOR

d. Delegation

• The delegator must provide the effective date of the delegation, and check the box with the applicable delegation type.

e. Signature

• The delegator must digitally or manually sign in the appropriate signature box. Digitally signed forms must be emailed to Fiscal Service.

• The delegator must print his/her full name and agency.

SECTION III - POINT OF CONTACT

f. Information

• Enter the contact information for the delegator. An email address must be provided for the point of contact.

SECTION IV - FISCAL SERVICE VALIDATION

For Fiscal Service use only.

PRIVACY ACT STATEMENT

AUTHORITY: 5 U.S.C. 301 and 31 U.S.C. 3321, 3325, authorize the collection of this information.

PURPOSE: These records are collected to allow Federal agencies to authorize the designation of those individuals appointed to serve in disbursing roles, and to allow Fiscal Service to 

maintain records of such appointments, records of any subsequent revocations or renewals in those roles, and document the authority of the disbursing actions taken by those individuals 

in execution of their roles.

ROUTINE USES: These records may be used by Fiscal Service Payment Management employees to verify the authority of the heads of agencies sending these forms, received to 

designate, revoke, and renew individuals appointed to serve in disbursing roles, and to authorize those designations. Additionally, this information may be provided to appropriate 

Federal agencies responsible for investigating or prosecuting the violations of, or for enforcing or implementing, a statute, rule, regulation, or order, where the disclosing agency 

becomes aware of an indication of a violation or potential violation of civil or criminal law or regulation, or as otherwise allowed by Treasury/Fiscal Service System of Records Notice .009, 

Delegations and Designations of Authority for Disbursing Functions or other authorities.

DISCLOSURE: Furnishing this information is voluntary; however, failure to provide the requested information may result in not being considered for a specific disbursement-related function.