FMS 1133 Claim Against the United States for the Proceeds of a Go

PAYEE INSTRUCTIONS
FOR COMPLETING CLAIM FORM FS 1133, CLAIM AGAINST THE UNITED STATES FOR
THE PROCEEDS OF A U.S. TREASURY CHECK.

PAYEE ADDRESS

PLEASE READ AND FOLLOW THE INSTRUCTIONS
1. The check you inquired about has been cashed. The Treasury’s Check Claims is responsible for handling claims involving U.S.
Treasury checks.
2. Examine the attached check copy, especially the handwritten and/or stamped endorsements on the back.
3. Pay particular attention to the date of the check. If the check is not the one you are missing, or if you have a question about the
check amount, contact the agency which authorized the payment (Social Security Administration (SSA), Veterans Affairs
(VA), Internal Revenue Service (IRS), etc.) giving them enough information to locate the check in question.
4. If the check copy shows that the check was deposited at your financial organization, take the check copy to the bank, credit union
or savings and 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 (Pages 2 and 3) and check copy.
5. If you signed the check or the check was cashed with your permission, or if for any reason you do not want to make claim for the
amount of the check, do not return the Claim Form.
6. Answer all questions on both pages. Part 1 is for use in the criminal investigation and recovery of funds from the bank. Part 2 is
for criminal and administrative investigation and handwriting analysis. Signatures are required for Parts 1 and 2 since this form is
routed to two separate destinations for processing.
7. If you did not sign the check, did not give someone else permission to cash the check or did not benefit in any way from the
check, fill in BOTH PAGES of the Claim Form. It is important that you:
A. ANSWER ALL QUESTIONS ON BOTH PAGES (items 1 through 8 on page 2) (items 9 through 16 on page 3).
Please fill out the Claim Form in Black ink.
B. Sign your name personally where indicated. If the check is issued to two payees, both payees must sign the Claim Form.
C. The signature of a Witness is required only when one or both payees sign their names with a mark.
D. RETURN THE CHECK COPY, YOUR COMPLETED FS 1133 CLAIM FORM TO THE FOLLOWING ADDRESS.

U.S. Department of the Treasury
Bureau of the Fiscal Service
Claims Adjudication Section
P. O. Box 51318
Philadelphia, PA 19115-6318

PAYEE: RETAIN THIS COPY FOR YOUR RECORDS.

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PART 1

CLAIM AGAINST THE UNITED STATES FOR THE
PROCEEDS OF A GOVERNMENT CHECK

OMB No. 1500-0010

Please refer to the Privacy Act Statement following this form, which you may keep for your records.

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 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 organization? Did someone else deposit this
check to an account that you could use?
5. Was this check cashed with your permission?
6. Did you receive any money or benefit in any way from
this check (e.g. household expenses, child support,
etc.)? If so, explain ( and include amount if known).
7. If your present name is different from that on the face of 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.
THIS CLAIM IS MADE FOR THE PROCEEDS OF THE ABOVE CHECK. IF YOU CASH BOTH ORIGINAL AND ANY SETTLEMENT CHECKS, THE
OVERPAYMENT MUST BE PROMPTLY REFUNDED. FAILURE TO DO SO COULD RESULT IN LEGAL ACTION. BE SURE TO INCLUDE THE ABOVE CHECK
AND SYMBOL NUMBERS WITH YOUR REFUND.

SIGN
HERE

2nd Payee’s Signature (if check drawn to two payees)

Payee’s Signature

2nd Payee’s assigned I.D.
No. (SSA, VA, IRS, Etc.)

Your assigned I.D.
No. (SSA, VA, IRS, Etc.)
Signature of Witness (ONLY if Payee(s) Signed by Mark)

DEPARTMENT OF THE TREASURY
Bureau of the Fiscal Service
EDITION OF 7-89 IS OBSOLETE

FS

FORM
4-94

1133

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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 advise the Post
Office and agency which authorized payment.

Address

Apt.
Zip

Yes

No

11. Did anyone other than yourself have the opportunity to
receive your mail? If so, who?
12. Did you lose any identification which might have been
used by someone else to cash your check? Explain.
13. Do you have information concerning the cashing of the
check? If so, explain. (Please use additional paper if
necessary.)
14. Where did you usually cash or deposit your check at
the time this check was cashed?

15. Clearly print your current mailing address.

Address

Apt.
Zip

16. If you are employed, give the name, address, and
telephone number of your current employer.
I certify that all the above questions have been answered
truthfully to the best of my knowledge.

SIGN
HERE

Name
Address

Telephone No. (

)

nd

Payee’s Signature

2 Payee’s Signature (if check drawn to two payees)

Date

Date

Give your home address, telephone number and/or a
number where you can be reached.

Address

Zip

Telephone No. (

)

Other No.

)

(

To expedite the settlement of your claim, sign your name three (3) times below for handwriting comparison.
Payee’s Signature

2nd Payee’s Signature

1.

1.

2.

2.

3.

3.

Be sure to detach and 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 agency given on the instruction page, and advise the Post Office of your forwarding
address. COMPLETE BOTH PAGES OF THIS CLAIM FORM. You must return the check copy or we will be unable to process your claim.

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

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PRIVACY ACT STATEMENT
AUTHORITY: 31 U.S.C. 321 3321, 3325, 3327, 3343; 31 CFR Parts 235 and 245; and Executive Orders 9397 and 13478 authorize the
collection of this information.
PURPOSE: These records are collected to allow the Department of the Treasury to process a payee’s claim for the proceeds of a
government check.
ROUTINE USES: These records may be disclosed to the endorsers on the government check that is subject to your claim, including
the banking industry for payment verification. This information may also be disclosed pursuant to the Department of the Treasury
System of Records Notices (SORNs) FMS .002 and FMS .003; including to Federal agencies, State and local law enforcement
agencies, congressional offices and media assistance offices on behalf of payee claimants; and agencies responsible for
investigating or prosecuting violations or potential violations of a civil or criminal law or regulation, or for enforcing or
implementing, a statute, rule, regulation or order; and courts, magistrates or congressional offices, as authorized or required by
law. The Executive Orders listed above authorize the use of your Social Security Number (SSN). Your SSN may be used to ensure
the accurate identification and retention of records pertaining to you and to distinguish you from other claimants.
DISCLOSURE: Furnishing this information (including your SSN) is voluntary; however, failure to provide the requested information
may result in a claim against the United States for the proceeds of a government check to be delayed or unable to be processed.

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