Form TFS 5135 TFS 5135 Voucher for Paymentof Awards Certified By The Mixed Clai

OMB No 1510-0037
Voucher No.

VOUCHER FOR PAYMENT OF AWARDS CERTIFIED BY THE MIXED
CLAIMS COMMISSION, UNITED STATES AND GERMANY
OR THE FOREIGN CLAIMS SETTLEMENT COMMISSION
OF THE UNITED STATES or for the payment of accounts divested
under Title II of the International Claims Settlement Act of 1949, as amended.
DEPARTMENT OF THE TREASURY
RETURN TO:
FINANCIAL MANAGEMENT SERVICE
DEPARTMENT OF THE TREASURY
3700 EAST-WEST HIGHWAY, RM 6F03
FOREIGN CLAIMS SECTION
HYATTSVILLE, MD 20782

NAME AND ADDRESS OF PAYEE
Docket or
Claim No.

xx

Claim of

$

International Claims Settlement Act of 1949, as amended
Title II of the War Claims Act of 1948, as amended
The Settlement of War Claims Act of 1928, as amended

NOTICE
FINES, PENALTIES, AND FORFEITURES AND IMPOSED BY LAW FOR MAKING OF FALSE OR FRAUDULENT
CLAIMS AGAINST THE UNITED STATES OR MAKING OF FALSE STATEMENTS IN CONNECTION THEREWITH.
(31 U.S.C.231, 18 U.S.C. 1001)
STATEMENT
I state that I am personally entitled, or duly authorized on behalf of the estate, partnership or corporation which is
entitled, to make claim for and to receive the award (share) payment described on this voucher in the following
capacity, and I hereby make claim for such payment.

Date

Signature

Address:

Taxpayer Identification Number / SSN is required to make payment :
APPROPRIATION: 20X6314

Date

TFS FORM 5135
9-80
7/85

Paid by
Check No.
& Symbol

Schedule No.

DEPARTMENT OF THE TREASURY - FISCAL SERVICE

FINANCIAL MANAGEMENT SERVICE

on United States
Treasury in favor
of payee named
above.