Attorney in Fact Form
Attorney in Fact Form
Attorney in Fact Form
· Once the form is processed, the Attorney-in-Fact, Guardian or Conservator will be authorized to act on your behalf.
· The Attorney-in-Fact, Guardian or Conservator who completes this form must also provide a valid and non-expired copy of one
of the following: U.S. Driver's License, U.S. State ID, Passport or Passport Card.
· Please sign carefully in blue or black ink only and mail this form and your supporting documents to: Mercedes-Benz Financial Services
USA LLC, First Class Demand Notes, P.O. Box 535406, Pittsburgh, PA 15253.
· Please call 1-866-242-0120 with any questions regarding this form, M-F from 8 a.m. to 7 p.m. ET.
The following notice is from The Bank of New York Mellon, the Processing Agent for First Class Demand Notes:
To help the government fight the funding of terrorism and money laundering activities, Federal law requires the collection, verification, and
recording of information that identifies each person who opens an account.
What this means for you: When you open an account, you will be asked for your name, address, date of birth and other information that
will allow you to be identified. You may also be asked to provide your driver's license or other identifying documents.
9400-
Joint Owner's or Co-Trustee's Name (If Applicable) Last 3 Digits of SSN (if applicable)
2. Indicate What Type of Authority You are Establishing for the Note
I am establishing a Power of Attorney ("POA") for the Note listed above
3. Provide Your Personal Information for POA, Guardian, or Conservator (All Information is Required Unless Indicated)
First Name, Middle Initial, Last Name Suffix
Driver's License Number or State ID if Driver's License Unavailable Issuing State Primary Telephone Number Secondary Telephone Number (Not Required)
Residential Address (Street Address, City, State and Zip Code) CANNOT BE A P.O. BOX
Previous Address if less than 2 Years at Residential Address (Street Address, City, State and Zip Code)
Have you included a copy of an acceptable form of identification and the supporting documents required?
Mail to: Mercedes-Benz Financial Services USA LLC, First Class Demand Notes,
84-001-2009 (02/17)
P.O. Box 535406, Pittsburgh, PA 15253