FS Form 1133-A Claim Against the United States for Proceeds of a Govern

PAYEE INSTRUCTIONS FOR COMPLETING FORM FS 1133-A, CLAIM AGAINST THE UNITED
STATES FOR THE PROCEEDS OF A U.S. TREASURY PAYMENT.
U.S. TREASURY
OMB No. 1530-0010
Bensalem, PA 19020

You are receiving this letter because you recently filed a claim with the Social Security Administration (SSA).
You told us that a recent SSA electronic benefit payment was not received. We are working to resolve this
issue and need some additional information from you.
Our records show that a payment was made to the person and account listed below. If this information
is not correct, fraud maybe involved. Please carefully review the following information, then complete the
included FS 1133-A Claim Form (3 pages) and return the completed form to the address at the bottom
of this page.

Payee Name:
Payee ID (SSN):
Agency Paid By:
Payment Amount:
Payment Date:
Financial Institution:
Account Number:
Note: If you use a pre-paid card to receive benefits, the financial institution can be found on the back of the card.

ACTION REQUIRED:
1.

Please keep this page for your records.

2.

Answer all questions on the included form truthfully and to the best of your knowledge. If you have
questions while completing the form, please call 1-855-868-0151, option 1 for help.
IMPORTANT: Failure to complete and return this form may lead SSA to find that
you have been overpaid. SSA may seek to recover that overpayment from you.

3.

Initial the top of each page and return the completed/signed form to the address below. You can expect
a resolution within 30 days of receipt.

Philadelphia Financial Center
Non-Receipts Section
P.O. Box 603
Bensalem, PA 19020

Claim Number:

02/21/2018

Initial ____________
CLAIM AGAINST THE UNITED STATES FOR THE
PROCEEDS OF A GOVERNMENT PAYMENT - FS 1133-A CLAIM FORM
Your Social Security Number and other information requested will allow the Department of the Treasury to process your claim for the proceeds of a government payment. The collection
of information is made pursuant to the Department of the Treasury's authority to consider your claim, which is found at Title 31 of the Code of Federal Regulations, Part 210.
Your social security will be used to ensure the accurate identification and retention of records pertaining to you and to distinguish you from other claimants. Furnishing your
social security number and the other requested information is voluntary. However failure to provide any part of the requested information may delay the processing of your claim.

Payee Name:
Payee ID (SSN):
Agency Paid By:
Payment Amount:
Payment Date:

Answer all of the following questions truthfully and to the best of your knowledge.
Please select ONE answer for each question.
WARNING: Title 18, Sec. 287, U.S. Code: Whoever makes or presents to any person or officer 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 fined not more than $10,000 or imprisoned not more than five
years, or both.

1. Did you receive the payment listed in this letter?
No, I have not received it yet.
Yes, I did receive it. Please continue to complete and return this entire form.
2. I signed up for my benefits to be...
Deposited into my bank account.
Financial Institution: ___________________________________________
Account Number:

___________________________________________

I signed up to receive my payments via Prepaid Card.
Financial Institution:

___________________________________________

Pre-paid Card Number: ___________________________________________
Note: If you use a pre-paid card to receive benefits, the financial institution can be found
on the back of the card. A pre-paid card is a card that has money stored directly on it and
and is not linked to you personal bank account.
Sent to me by paper check.
3. Were any expenses paid for you with this payment, such as child support or to an assisted living
facility? These expenses may have been paid on your behalf or removed due to a wage garnishment
(money taken out of your earnings to pay a debt).
No expenses were paid for me.
Yes, some expenses have been paid for me with this payment.
If yes, please describe the expenses that were paid for you with this payment:

_________________________________________________________________________________
_________________________________________________________________________________

FS Form 1133-A (PAGE 1)

Claim Number:

02/21/2018

Initial____________
4. Did you authorize anyone to use your name or personal information to apply for your benefit payment, open a
bank account, or receive a pre-paid card for this payment?
No, I did not authorize anyone else.
Yes, I authorized the following person:
Name:

_________________________________________________

Address: _________________________________________________
City:

_____________________________

State: _______

Zip Code ___________

Relationship:
____________________________________________________________________
If there are any additional authorized persons, please provide their name and relationship to you:

_______________________________________________________________________________
_______________________________________________________________________________
5. Do you know of any unauthorized person who may have received this payment?
No, I do not know who opened the account or received the payment.
Yes, the following person opened the account or received the payment instead of me:
Name:

________________________________________________

Address: ____________________________________________
City:

_____________________________

State: _______

Zip Code ___________

Relationship:
____________________________________________________________________
If there are any additional unauthorized persons, please provide their name and relationship to you:

_______________________________________________________________________________
_______________________________________________________________________________

6. In the past year, has your identification such as a driver's license, recently been misplaced, lost, or stolen?
No, my identity has not been stolen.
Yes, my identity was stolen in the past year.
If yes, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________

7. In the past year, has your identity been stolen? Stolen identities, such as your name or socal security
number, can be used to open a credit card or to sign up for benefits in your name.
No, my identity has not been stolen in the past 12 months.
Yes, my identity has been stolen in the past 12 months.
If yes, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________

FS Form 1133-A (PAGE 2)

Claim Number:

02/21/2018

8. In the past year, have you filed a police report related to your identity being stolen or about this missing payment?
No, I have not filed any police reports.
Yes, I filed a police report for identity theft or about this payment in the past year.
If yes, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________
9. In the past year, have you set a credit fraud alert on your credit reports? A credit fraud alert is a
warning to credit agencies that your identity may have been put at risk.
No, I have not placed any fraud alerts on my credit reports.
Yes, I placed fraud alerts on my credit reports in the past 12 months.
If yes, please provide the report number:
_________________________________________________________________________________________
_________________________________________________________________________________________
10. Is there any other information available about your account, benefits, or your payments that will help us to resolve this specific
missing payment? Please include any errors or inconsistencies you noticed in your payment information in this letter.
No, I have no further information.
Yes, there is more information regarding the above missing payment.
If yes, please describe:
_________________________________________________________________________________________
_________________________________________________________________________________________
WARNING: Title 18, Sec 287, US Code: Whoever makes or presents to any person or officer 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 fined not more than $10,000 or imprisoned not more than five years, or both.

I certify all of the above questions were answered truthfully to the best of my knowledge.
Signature:
Address:
City/State/Zip:
Phone Number:

_______________________________________
Date: _____________
______________________________________________________________
______________________________________________________________
______________________________________________________________

Please return your signed and completed FS 1133-A claim form to the following address:
Philadelphia Financial Center
Non-Receipts Section
P.O. Box 603
Bensalem, PA 19020
You can expect a resolution within 30 days of receipt.
Be sure to keep the first page (Payee Instructions) for your records.
Notice Under the Paperwork Reduction Act:
We estimate it will take you about 10 minutes to complete this form. However, you are not required to provide information requested unless a valid OMB control number
is displayed on the form. Any comments or suggestions regarding this form should be sent to the Bureau of Fiscal Service, Forms Management Officer, Parkersburg,
WV 26106-1328. DO NOT SEND the completed form to the above address; send to the correct address shown in 'Where to send' in the Instructions.

FS Form 1133-A (PAGE 3)

Claim Number

02/21/2018