Form 6314 Assignment Form

RESET
FORM

ASSIGNMENT

              OMB No. 1510‐0035 
              Exp. Date: 

KNOW ALL MEN, BY THESE PRESENTS: That I, ___________________________________________________
(name of awardholder-assignor)
(state capacity when other than an individual capacity) residing at _________________________________________________
________________________________for valuable consideration, the receipt whereof is hereby acknowledged, do hereby
assign, transfer, and set over unto __________________________________________________ _________________ of my
(name of assignee)
(percentage assigned)
right, title and interest in and to the unpaid balance of the award of the Foreign Claims Settlement Commission of the United
States to _______________________________________________, Claim No. _______________,
(name of original awardee)
Decision No. ___________. I hereby request and direct the Secretary of the Treasury to make payment directly to
___________________________________ at ________________________________________________________________.
(assignee’s name)
(address of assignee)
IN WITNESS WHEREOF, I have hereunto set my hand and seal this ______day of ______________, 20 ________
at ________________________________________________________.
________________________________________________________
(signature of awardholder-assignor)
ACKNOWLEDGEMENT
STATE OF ____________________________)
ss:
COUNTY OF __________________________)
Before me, _____________________________________ in and for the County of _________________,
State of ______________________________, on this day personally appeared ______________________________________
known to me to be the person ______ whose name ______ subscribed to the foregoing instrument and acknowledged to me
that ______ he ______ executed the same for the purposes and consideration therein expressed.
GIVEN under my hand and seal of office, this ______ day of ______________________, A.D. 20______.

____________________________________________
(signature of Notary or other official)

(Seal)

My commission expires ______________________.
“The Federal government may not conduct, and the public is not required to respond to, a collection of information that does 
not display a currently valid OMB control number.  The control number for this collection is 1510‐0035.”   

DEPARTMENT OF THE TREASURY
FMS Form 6314
7-10
FINANCIAL MANAGEMENT SERVICE