FS Form 210DA Department of the Treasury | Bureau of the Fiscal Service Revised April 2021

DESIGNATION FOR AGENT TO RECEIVE AND DELIVER CHECKS

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:* Division: 

Phone Number:* E-mail:*

Authorized Agency Location Codes (ALC):*

Additional ALCs Attached

b. Request Type [Check One]

Original Designation Update (Comments Required) Revocation

Comments:

c. Certifying Officer Training By signing below, I affirm I completed the Fiscal Service Certifying Officer Training on*

d. Signature

Note one: To submit digitally, both the designee and designator 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 designator ink signature is not required for a registered user to submit optional INK signature samples via their registered e-mail.

d.1. Digital Signature d.2. Ink Signature Samples

SECTION II – DESIGNATOR

e. Designation

In accordance with the authority vested in me by the head of this agency or his/her designee, I hereby designate to the individual whose name and 

signature samples appear above, the authority to act as a Designated Agent, effective

f. Signature

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

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

f.1. Digital Signature f.2. Ink Signature

Full Name:*

Agency:*

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

g. Information

Name:*

Address:

E-mail:* 

 Phone:

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

OR

Date

OR

Date
FS Form 210DA Department of the Treasury | Bureau of the Fiscal Service Revised April 2021

INSTRUCTIONS FOR FS FORM 210DA

1. Use this form to designate Designated Agents (DA) who will have authority to receive checks for specific Agency Location Codes (ALCs) from the 

Bureau of the Fiscal Service, for subsequent delivery to the payee(s). In accordance with provisions of 5 U.S.C. 301; 31 U.S.C. 3321, 3325, authority 

is hereby designated to the individual named on the form FS 210DA to act as an agent of the disbursing officer for the purpose of receiving and 

distributing such checks. The DA will be guided by the instructions printed below and such other instructions as may be directed to him/her from 

time to time. 

2. 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 designation renewal 

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

3. For “Effective Date,” enter the date that the designation is to become effective. The actual effective date will be the date the designation is 

accepted by Fiscal Service.

4. Authority for only one individual may be designated 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.

• List all ALCs for which the Designee will have authority to certify payments.

b. Request type

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

- Check “Original Designation” for new designations.

- Check “Designation Update” to update information for existing designations.

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

a new FS Form 210DA must be submitted re-designating that authority.

c. Certifying Officer Training

• This box must be checked to affirm that the training has been completed and provide the date taken.

d. Signature

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

SECTION II - DESIGNATOR

e. Designation

• The designator must provide the effective date of the designation.

f. Signature

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

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

SECTION III - POINT OF CONTACT

g. Information

• Enter the contact information for the designator. 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.