Form 13818 Form 13818 Limited Payability Claim Against the United States For t

CLEAR
Limited Payability
CLAIM AGAINST THE UNITED STATES
FOR THE PROCEEDS OF AN INTERNAL REVENUE REFUND CHECK
Date:
Tax Examiner:

Taxpayer Identification Number:
Check Amount:
Symbol #
Check #
Date of Check:

Payee Name and Address:

Tax Year:
Form:
LIMITED PAYABILITY CLAIM – FOR IRS USE ONLY
COMPLETE BOTH SIDES OF THIS FORM
IF NOT RETURNED IN 30 DAYS YOUR CASE WILL BE CLOSED
WARNING: TITLE 18, Sec. 527, U.S. Code: “Whoever makes or presents to any person or office in the civil, military,
or naval service, of the United States, or to any department or agency thereof, any claim upon or against the United
States, or to any department or agency thereof, knowing such claim to be false, fictitious, or fraudulent, shall be
imprisoned not more than five years and shall be subject to a fine in the amount provided in this title.”
1. Did you receive this check?
2. Did you sign your name on this check?
3. Did you cash this check?
4. Did you deposit this check in a bank, credit union or
other financial institution? Did someone else deposit this
check into an account that you could use?
5. Was this check cashed with your permission?
6. Did you receive any money or benefit in anyway from
this check (e.g. household expenses, child support, etc.)?
If so, explain. (Include amount if known.)
7. If your present name is different from the payee
name on the check, explain why.
8. If you are making claim for this check and it is not
made out to you, state your relationship to the payee.
Explain why the payee cannot sign.
9. Did you ever live or receive mail at the address on
the front of this check?
10. What was your mailing address on the date this
check was issued? If you moved, did you notify the Post
Office and Internal Revenue Service of your new
address?
11. Did anyone other than yourself have the opportunity
to receive your mail? If so, who?
Form 13818 (Rev. 5-2007)

Catalog Number 48857Z

Department of the Treasury – Internal Revenue Service

12. Did you lose any identification that might have been
used by someone else to cash your check? If so, explain.
13. Do you have any information concerning the
cashing of the check? If so, explain. (Attach additional
paper if necessary.)
14. Where did you usually cash or deposit your checks
at the time this check was cashed?
15. If you submitted the claim for this refund more than
one year after issue date, explain why. (Attach additional
paper if necessary.)
16. Please clearly print your current mailing address
and provide a telephone number where you can be
reached.

Address
Apt.
City
ZIP Code

State
Telephone No. (
17. If you are employed, print the name , address and
telephone number of your current employer.

)

Company Name
Address
City
ZIP Code

State
Telephone No. (

)

I certify that all the above question have been answered truthfully and to the best of my knowledge.
Payee’s Signature

Second Payee’s Signature (If check drawn to two payees)

SIGN
HERE:
Your Taxpayer Identification Number

Second Payee’s Taxpayer Identification Number

SIGNATURE OF WITNESS
(Only of Payee(s) Signed by Mark)

Form 13818 (Rev. 5-2007)

Catalog Number 48857Z

Department of the Treasury – Internal Revenue Service

IF YOU CASH BOTH THE ORIGINAL AND ANY REPLACEMENT CHECKS, THE OVERPAYMENT MUST BE
PROMPTLY REPAID. FAILURE TO DO SO COULD RESULT IN LEGAL ACTION. BE SURE TO INCLUDE THE
ABOVE CHECK AND SYMBOL WITH YOUR REPAYMENT.
To expedite the resolution of your claim, sign your name three (3) more times below for handwriting comparison.
Payee’s Signature

Second Payee’s Signature

1.

1.

2.

2.

3.

3.

Be sure to retain the Payee Instruction page for your records. If you move before your claim is settled, send your new
address along with the check and symbol numbers to the address provided on the enclosed envelope. Please be sure to
advise your local Postal Service of your forwarding address. You must RETURN THE COPY OF THE CHECK, we
provided, or we will be unable to process your claim. Be sure to complete all parts of the claim form.

LOST OR STOLEN CHECKS CAN BE AVOIDED!!
ASK YOUR LOCAL FINANCIAL ORGANIZATION ABOUT THE DIRECT DEPOSIT PROGRAM

Form 13818 (Rev. 5-2007)

Catalog Number 48857Z

Department of the Treasury – Internal Revenue Service

PAYEE INSTRUCTIONS

FOR COMPLETING THIS CLAIM AGAINST THE UNITED
STATES FOR THE PROCEEDS OF AN INTERNAL REVENUE
REFUND CHECK

Claimant Name and Address:

LIMITED PAYABILITY CLAIM –
FOR IRS USE ONLY.
Privacy Act and Paperwork Reduction Act Notice: We ask for the information on this form to carry out the Internal
Revenue laws of the United States. You are required to give us the information. We need it to ensure that you are
complying with these laws and to allow us to determine the correctness of your claim or the right amount of payment.
Your Social Security Number and the other information are being requested in order that the Department of the
Treasury can process your claim for a government check. The authority of requesting your social security number is 26
U.S.C. section 6109. If you cannot or will not furnish the information, the processing of your claim may be delayed. The
authority to consider your claim is found in part, at 31 United States Code, section 3331 and 3343.
You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act
unless the form displays a valid OMB control number. Books or record relating to a form or its instructions must be
retained as long as their contents may become material in the administration of any Internal Revenue law. Generally,
tax returns and return information are confidential, as required by Code, section 6103. The time needed to compete
and file this form and related schedules will vary depending on individual circumstances. The estimated average times
are: [get this information from Forms and Pubs and insert.]

PLEASE READ AND FOLLOW THESE INSTRUCTIONS
1. The check you inquired about has been cashed. Examine the attached check copy, especially the handwritten
and/or stamped endorsement on the back of the check.
2. Pay particular attention to the amount and date of the check. If this check is not the one you are missing or if you
have a question about this matter, please contact the Internal Revenue office at the end of the page.
3. If the check copy shows the check was deposited at your financial institution, take the copy to your bank, credit
union or savings & loan and ask them to verify that your account was credited. If you are unable to settle this matter,
complete and return the Claim Form and check copy.
4. If you endorsed the check or the check was cashed with your permission, or if for any reason you do not want to
pursue the claim for this refund, do not return the Claim Form.
5. Provide any information you may have about the negotiation of the check. Attach additional paper if necessary.
6. If you did not sign the check or give anyone else permission to cash the check or did not benefit in anyway from the
proceeds of the check:
A. ANSWER ALL THE QUESTIONS ON BOTH SIDES OF THE FORM.
B. Sign your name in all spaces where it is requested. If the check is issued to two payees, both payees
must sign the Claim Form. Sign or print your name as you usually do.
C. The signature of a Witness is required when one or both payees sign their name(s) with a mark.
D. RETURN THE CHECK COPY, THE COMPLETED FORM AND ANY ATTACHMENTS IN THE
ENCLOSED RETURN ENVELOPE:
If you have questions about this matter, please call us toll-free at 1-800-829-0922 if this refund was issued from an
individual return, or 1-800-829-8374 if from a business return. RETAIN THESE INSTRUCTIONS, WITH THE PRIVACY
ACT/PAPERWORK REDUCTION ACT NOTICE FOR YOUR RECORDS.
Form 13818 (Rev. 5-2007)

Catalog Number 48857Z

Department of the Treasury – Internal Revenue Service